Is bilateral endoscopic sinus surgery and bilateral submucous resection of the inferior turbinates with image guidance medically indicated for a 46-year-old male patient with a history of anosmia, chronic rhinosinusitis, nasal polyps, and severe hypertrophied turbinates, who has undergone a computed tomography (CT) sinus scan and is taking trazodone, without prior allergy testing?

Medical Necessity Assessment: Bilateral Endoscopic Sinus Surgery and Turbinate Reduction

Primary Determination

This surgery is NOT medically necessary at this time due to two critical missing requirements: CT sinus imaging results must be reviewed to confirm objective evidence of chronic rhinosinusitis, and formal allergy testing must be completed with appropriate allergic management optimized before surgical intervention can be approved. 1

Critical Missing Documentation

CT Imaging Results Required

• Objective radiologic evidence of disease is an absolute requirement before endoscopic sinus surgery can be deemed medically necessary for chronic rhinosinusitis with nasal polyps 1
• The European Position Paper on Rhinosinusitis 2020 explicitly requires "objective evidence of disease by CT imaging" for surgical candidacy in chronic rhinosinusitis lasting >12 weeks 1
• While CT imaging has been performed, surgery cannot be approved until results demonstrate mucoperiosteal thickening, ostiomeatal complex obstruction, or other radiologic evidence of chronic sinus disease 1
• CT findings must correlate with clinical symptoms to justify surgical intervention 2

Mandatory Allergy Testing and Management

• The American Academy of Allergy, Asthma, and Immunology requires that underlying allergic conditions be evaluated and treated appropriately before turbinate reduction can be considered medically necessary 1
• This patient has clear allergic symptoms (itchy watery eyes, sneezing) and uses albuterol for asthma, yet has not undergone formal allergy testing—this represents incomplete workup 1
• Patients with chronic rhinosinusitis and allergic rhinitis fare better after endoscopic sinus surgery if their allergies are managed optimally 3
• Turbinate reduction surgery should only be offered after the underlying allergic condition has been assessed and treated, with inadequate response to medical management including intranasal steroids and antihistamines 3, 4

Clinical Criteria Assessment

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) Diagnosis

The patient does meet diagnostic criteria for CRSwNP:

• Symptoms present for "a number of years" exceeds the required >12 weeks duration 3, 1
• Two or more cardinal symptoms are documented: nasal congestion, anosmia (complete loss of smell), and bilateral midface pain/pressure 1
• Nasal polyps are present in 20% of patients with chronic rhinosinusitis and typically present with nasal congestion, nasal obstruction, and anosmia 5

Medical Management Documentation

The patient has completed adequate medical management trials:

• Documented failure of intranasal corticosteroids (specific medication, duration, and compliance required) 2, 1
• Antihistamine trial with no improvement 1
• Sinus surgery should be reserved for patients who do not satisfactorily respond to medical treatment 3
• The majority of chronic rhinosinusitis patients respond to appropriate medical treatment as effectively as surgical treatment 3

Turbinate Hypertrophy Criteria

The patient meets criteria for turbinate reduction pending allergy workup completion:

• Marked turbinate hypertrophy documented as "severely hypertrophied" on physical examination 1
• Inadequate response to intranasal steroids and antihistamines 1
• Symptoms affecting quality of life: severe nasal congestion, complete anosmia for years, chronic cough, dyspnea 1
• Turbinate reduction should only be considered after inadequate response to medical management including intranasal steroids and antihistamines 3, 4

Algorithmic Approach to Approval

Step 1: Review CT Sinus Imaging (Immediate Priority)

• Obtain and review CT sinus results to demonstrate mucoperiosteal thickening, ostiomeatal complex obstruction, or polyp disease 1
• CT must show objective evidence of chronic sinus disease correlating with clinical symptoms 2, 1
• Assess anatomical complexity and proximity to orbit/skull base to justify image guidance (CPT 61782) 1

Step 2: Complete Formal Allergy Testing (Immediate Priority)

• Perform skin prick testing to common inhalant allergens 1
• Document specific allergen sensitivities given patient's allergic symptoms (itchy watery eyes, sneezing) and asthma 1

Step 3: Optimize Allergy Management (4-Week Minimum)

• Implement allergen-specific immunotherapy if indicated based on testing results 1
• Establish environmental allergen avoidance measures 1
• Trial of allergen-specific medical management for minimum 4 weeks 1
• Continue intranasal corticosteroids with documented compliance 3, 2

Step 4: Re-Evaluate for Surgical Candidacy

• If CT confirms extensive sinus disease AND allergy management has been optimized without improvement, surgery becomes medically necessary 1
• Functional endoscopic surgery is superior to minimal conventional procedures including polypectomy 3
• In chronic rhinosinusitis patients not previously operated, surgical conservatism is recommended with extent of surgery tailored to extent of disease 3

Surgical Procedure Appropriateness (Pending Prerequisites)

Bilateral Endoscopic Sinus Surgery (CPT 31253 x2)

• Once CT confirms disease and allergy management is optimized, bilateral endoscopic sinus surgery is appropriate for chronic rhinosinusitis with nasal polyps refractory to medical treatment 3
• Major complications occur in less than 1%, and revision surgery is performed in approximately 10% within 3 years 3
• Substantial symptomatic improvement is generally observed in chronic rhinosinusitis with polyps 3
• Topical nasal steroids are the treatment of choice for nasal polyps, but surgery is reserved for patients in which polyps cause severe obstruction or for whom medical therapy has failed 5

Bilateral Submucous Resection of Inferior Turbinates (CPT 30140 x2)

• Septoplasty (CPT 30520) is preferred over submucous resection (CPT 30140) due to higher success rates (77-89%) and better tissue preservation 2
• Submucous resection with lateral outfracture is the gold standard for combined mucosal and bony hypertrophy, achieving optimal long-term normalization of nasal patency 4
• Whenever there is septal deviation, typically there is compensatory turbinate hypertrophy on the opposite side 3
• Combined septoplasty with turbinate reduction provides better long-term outcomes than septoplasty alone when both conditions are present 2

Image Guidance (CPT 61782)

• Image guidance is appropriate given the extensive planned procedures (ethmoidectomy, maxillary antrostomy, frontal sinus endoscopy, sphenoid endoscopy) and concern for entering critical structures 1
• However, this determination requires CT imaging to assess anatomical complexity and proximity to orbit/skull base 1

Common Pitfalls to Avoid

Do Not Approve Based on Physical Examination Alone

• Do not approve surgery based solely on dramatic physical examination findings without radiologic confirmation 1
• Only 26% of septal deviations are clinically significant, and assuming all septal deviations require surgical correction is a common pitfall 2
• Approximately 80% of the general population has some degree of septal asymmetry 2

Do Not Proceed Without Addressing Allergic Component

• Do not proceed with turbinate reduction without addressing underlying allergic component—this leads to suboptimal outcomes and potential surgical failure 1
• Patients with chronic rhinosinusitis and allergic rhinitis fare better after endoscopic sinus surgery if their allergies are managed optimally 3
• Continued medical management of underlying rhinitis is required even after surgery 2

Recognize Multifactorial Symptoms

• The patient's persistent cough may be related to untreated allergic rhinitis with postnasal drainage rather than purely structural obstruction 1
• Anosmia is highly predictive of chronic rhinosinusitis and represents significant functional impairment 2

Trazodone Consideration

• While trazodone use is noted in the history, there is no evidence that this medication contraindications sinus surgery or affects surgical outcomes
• No medication adjustments are required based on trazodone use alone

Final Recommendation

Defer approval pending:

1. CT sinus imaging review demonstrating objective evidence of chronic rhinosinusitis 1
2. Completion of formal allergy testing with skin prick testing 1
3. Minimum 4-week trial of optimized allergy management based on testing results 1

Once these prerequisites are met and documented, bilateral endoscopic sinus surgery with bilateral turbinate reduction (preferably septoplasty rather than submucous resection) with image guidance would be medically necessary for this patient with chronic rhinosinusitis with nasal polyps and severe turbinate hypertrophy refractory to medical management. 3, 2, 1