Endoscopic Sinus Surgery

Rhino-sinusitis refers to symptomatic inflammation of the para-nasal sinuses and nasal cavity that may or may not have an infective component and includes nasal polyposis. Acute rhino-sinusitis (ARS) lasts up to 12 weeks and resolves completely. Chronic rhino-sinusitis (CRS) persists over 12 weeks and may involve acute exacerbations. Rhino-sinusitis is common, affecting approximately 15 % of the population and results in significant reduction in quality of life (QOL). The diagnosis is based largely on symptoms with confirmation by nasal endoscopy. Computerized tomography (CT) scans and magnetic resonance imaging (MRI) are abnormal in about 1/3 of the population, thus, they are not recommended for routine diagnosis; but should be reserved for individuals with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhino-sinusitis. Multiple therapies are used in the management of CRS with nasal polyps (CRSwNP) or without polyps (CRSsNP), including antibiotics, saline irrigations and sprays, intra-nasal and systemic glucocorticoids, and anti-leukotriene agents. Surgery should not be the first intervention in most cases, with the possible exception of allergic fungal rhino-sinusitis (Scadding et al, 2008; Hamilos, 2018).

Rosenfeld and colleagues (2015) provided an update of a 2007 guideline from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Foundation. This update furnished evidence-based recommendations to manage adult rhino-sinusitis. Changes from the prior guideline included a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhino-sinusitis (ABRS), and 3 new recommendations for managing CRS. The purpose of this multi-disciplinary guideline was to identify quality improvement opportunities in managing adult rhino-sinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals were to improve diagnostic accuracy for adult rhino-sinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, CT, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhino-sinusitis, including asthma, cystic fibrosis (CF), immunocompromised state, and ciliary dyskinesia.

The update group made strong recommendations that clinicians should perform the following:

Distinguish presumed ABRS from ARS caused by viral upper respiratory infections and non-infectious conditions

Confirm a clinical diagnosis of CRS with objective documentation of sino-nasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or CT.

Either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS

Prescribe amoxicillin with or without clavulanate as 1st-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic)

Re-assess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management

Distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sino-nasal symptoms

Evaluate the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, CF, immunocompromised state, and ciliary dyskinesia

Confirm the presence or absence of nasal polyps in a patient with CRS

Recommend saline nasal irrigation, topical intra-nasal corticosteroids, or both for symptom relief of CRS.

The update group stated as options that clinicians may:

Recommend analgesics, topical intra-nasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhino-sinusitis

Recommend analgesics, topical intra-nasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS

Obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS.

The update group made recommendations that clinicians:

Should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected

Should not prescribe topical or systemic anti-fungal therapy for patients with CRS.

The American Academy of Otolaryngology-Head and Neck’s “Clinical indicators for endoscopic sinus surgery in adults” (AAO-HNs, 2015 are listed below:

Allergic fungal rhino-sinusitis

Chronic rhino-sinusitis without nasal polyps (CRSsNP) with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to optimal medical treatment

Chronic rhino-sinusitis with nasal polyps (CRSwNP) with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to medical treatment

Complications of sinusitis, including extension to adjacent structures (i.e., orbit, skull base)

Mucocele

Recurrent acute rhinosinusitis (RARS)

Sino-nasal polyposis with nasal airway obstruction or suboptimal asthma control

Unilateral para-nasal sinus opacification, symptomatic or asymptomatic, consistent with CRSsNP, CRSwNP, fungus ball, benign neoplasm (i.e., inverted papilloma).

Antro-Choanal Polyps

Yuca and co-workers (2006) stated that antro-choanal polyp (ACP) is a benign maxillary sinus polyp that originates from the mucosa of the maxillary sinus, passes through a sinus ostium, and extends into the choana. The common presentation of ACP is unilateral nasal obstruction. These investigators discussed radiographic findings and differential diagnosis of ACPs by comparing them with data in the literature. This study included 19 surgically treated patients with ACPs (14 male, 5 female; median age of 24.5 years, range of 8 to 75 years) diagnosed by clinical examination, nasal endoscopy, and CT. Nasal obstruction was found in all cases; ESS was preferred for removal of the nasal part of ACPs in 13 cases. Only in 1 case, polypectomy combined with Caldwell-Luc operation and septoplasty was performed. The observed complications were as follows: minor hemorrhage in 3 cases, mild cheek swelling with pain in 2 cases, and infra-orbital hypoesthesia in 1 case. Histopathologic examination of ACPs revealed loose mucoid stroma and mucous glands, which were covered by respiratory epithelium. The authors concluded that ESS may be indicated in patients with ACPs because the function and capacity of the maxillary antrum are preserved. The greater portion of the antral part of polyp could be removed while leaving the healthy antral mucosa intact.

Eski and colleagues (2012) evaluated the long-term results of ESS and combined approach with Caldwell Luc procedure for the treatment of ACPs. Between January 2002 and December 2009, a total of 41 patients (24 males, 17 females; mean age of 34.7 years; range of 14 to 78 years) were retrospectively analyzed. Patients were divided into 2 groups according to treatment modality: group 1 included 26 patients who underwent ESS alone and group 2 included 15 patients who underwent ESS in combination with Caldwell Luc procedure. Both groups were compared for recurrence and complication rate; 17 of 41 patients were diagnosed with right-sided lesions, while 24 patients had left-sided lesions. Recurrence was seen in 3 patients, including 2 in group 1 and 1 in group 2. There was no statistically significantly difference between the groups in terms of recurrence and complication rate (p > 0.05). Mean follow-up was 50.5 months (range of 15 to 94 months). The authors concluded that current approach for the treatment of ACPs is ESS. However, combined approaches should be performed to avoid recurrences, unless removal of antral part of the ACP completely by endoscopic resection is possible. Selection of the combined techniques depends on the surgeon familiarity with the procedure and whether the patient is pediatric case. Combined approach with Caldwell Luc is a safe procedure in adults.

In a systematic review, Galluzzi and associates (2018) evaluated the recurrence rate after surgery for ACPs in children; secondly, these investigators analyzed the rate of recurrence for different types of surgery and the risk factors involved. They performed a systematic review searching PubMed and Medline databases including English-language published studies from June 1989 to October 2017 regarding surgical treatment of ACPs in children. These researchers included 13 studies, 8 were retrospective and 5 prospective, with 285 participants, the mean rate of recurrence after ACPs surgery was 15.0 % (95 % confidence interval [CI]: 11.0 to 20.0). Functional ESS (FESS) was the main type of surgery used for primary cases (75.4 %) followed by the combined approach (i.e., FESS with a trans-canine sinusoscopy or mini Caldwell-Luc (14 %)), the Caldwell-Luc (CWL) (8 %) and simple polypectomy (SP) (2.8 %). This analysis has demonstrated a significant reduction of recurrences using the combined approach 0 % (95 % CI: 0.0 to 8.0) compared with FESS 17.7 % (95 % CI: 12.8 to 23.4) or SP 50 % (95 % CI: 15.7 to 84.3) (p < 0.05); but no significant differences with CWL 9.1 % (95 % CI: 1.1 to 29.2) and others surgical approaches (p > 0.05). The analysis of the possible risk factors involved in recurrences were inconclusive. The authors concluded that recurrences of ACPs in children were still high; ESS was considered the 1st choice for primary treatment, while the external approach may be a valid option in case of recurrence. These investigators noted that it appeared that the combined approach could reduce recurrence rates in selected patients that could not be completely managed with endoscopy.

In a study on “Long-term outcomes of balloon sinuplasty for the treatment of chronic rhinosinusitis with and without nasal polyps” (Castro et al, 2021), patients with fungal sinusitis, mucocele, antro-choanal polyp or grade-III osteitis were excluded from the study.

Para-Nasal Sinus Mucoceles

Zukin and colleagues (2017) stated that para-nasal sinus mucoceles are benign cystic lesions originating from sinus mucosa that can impinge on adjacent orbital structures, causing ophthalmic sequelae such as decreased visual acuity (VA). Definitive treatment requires surgery. These investigators presented the first meta-analysis quantifying the effect of pre-operative visual function and time to surgery on post-operative VA outcomes. Data sources included PubMed, Ovid, Embase, Web of Science, and the Cochrane Library. Two independent authors systematically reviewed articles describing outcomes after ESS for para-nasal sinus mucoceles presenting with visual loss. Available data from case reports and series were combined to analyze the associations among pre-operative VA, time-to-surgery, and post-operative outcomes. A total of 85 studies were included that provided data on 207 patients. The average presenting VA was 1.57 logMAR (logarithm of the minimum angle of resolution), and the average post-operative VA was 0.21 logMAR, with visual improvement in 71.5 % of cases. Pre-operative VA of greater than or equal to 1.52 logMAR correlated with post-operative improvement greater than 1 logMAR (R = 0.4887, p < 0.0001). A correlation was found between a time-to-surgery of less than 6 days and post-operative improvement (R = 0.297, p < 0.0001). Receiver operator curve analysis of these thresholds demonstrated a moderately accurate prognostic ability (area under the curve: 75.1 for pre-operative VA and 73.1 for time-to-surgery). The authors concluded that visual loss resulting from para-nasal sinus mucoceles is potentially reversible in most cases, even those presenting with poor vision. When possible, surgery should be performed promptly after diagnosis, but emergency surgery did not appear to be necessary for vision restoration.

Sino-Nasal Inverted Papilloma

Jiang and colleagues (2017) stated that sino-nasal inverted papilloma (SNIP) is noted for its high rate of recurrence and malignant transformation. Although many clinical studies have demonstrated the effectiveness of the endoscopic approach for SNIP, the surgical strategy has been the subject of much debate. These researchers examined the effectiveness of the endoscopic endo-nasal approach in SNIP. They performed a systematic review of patients with a diagnosis of SNIP and who had surgery at the authors’ institution from June 2005 to March 2013. All the patients who had post-operative follow-up for greater than 2 years were enrolled. Each case was categorized into 1 of 4 stages as reported by Krouse. Demographic and tumor date, operative approach, complications, and recurrence rates were collected. A total of 125 patients were included in this study. There were 17 patients in stage 1, 40 in stage 2, 57 in stage 3, and 11 in stage 4. The overall recurrence rate was 8.0 %. There was no significant difference in recurrence among the stages (all p > 0.05). Recurrence after endoscopic endo-nasal approach (8.4 %) and a combined endoscopic and open exposure procedure (5.6 %) were not significantly different (p > 0.05). The recurrence rate was significantly (p < 0.05) higher in patients with revision (15.6 %) than in patients in the primary cases (3.8 %). A common site of tumor origin was recorded to be from the maxillary sinus (40.2 %); 20 % of recurrences were observed up to 5 years after surgery. The authors concluded that endoscopic surgery may be preferred for treating SNIP. The elevated recurrence rate after revision emphasized the significance of the first surgery. These researchers encouraged a follow-up period of at least 5 years.

Attlmayr and associates (2017) noted that SNIP is the most common benign tumor affecting the nose. There is a high rate of recurrence and a potential of malignant transformation. These investigators identified the best available management of this disease. They carried out a systematic review of the current English-language literature. Only original articles with a minimum follow-up of 1 year and an average follow-up of 2 years were included. A total of 1,385 patients from 16 case series were identified. The total recurrence rate for all patients was 11.5 %. Significantly lower recurrence rates were found for procedures using an attachment-oriented excision (recurrence of 6.9 %; p = 0.0001) and utilizing frozen sections (recurrence of 7.0 %; p = 0.0001). The authors concluded that there is a general trend towards endoscopic surgery. There may be some benefit to the use of attachment-oriented surgery and frozen sections.

Unilateral Pansinus Opacification

There is a lack of evidence on the use of balloon ostial dilation (balloon sinuplasty) for the treatment of unilateral pansinus opacification.

Revision Endoscopic Sinus Surgery

McMains and Kountakis (2005) reported objective and subjective outcomes after revision endoscopic sinus surgery (RESS) for CRS. These investigators performed a retrospective analysis of prospectively collected data in 125 patients requiring revision functional ESS (FESS) after failing both maximum medical therapy and prior sinus surgery for CRS. Patients were seen and treated over a 3-year period (1999 to 2001) in a tertiary rhinology setting; CT scans were graded as per Lund-MacKay and patient symptom scores were recorded using the Sino-Nasal Outcome Test 20 (SNOT-20) instrument. Individual rhino-sinusitis symptoms were evaluated on a visual analog scale (VAS; 0 to 10 scale) before and after surgery. All patients had a minimum 2-year follow-up. The mean number of prior sinus procedures was 1.9 +/- 0.1 (range of 1 to 7) and the mean pre-operative CT grade was 13.4 +/- 0.7. Patients with asthma and polyposis had higher CT scores than those without these processes. Pre-operative mean SNOT-20 and endoscopy scores were 30.7 +/- 1.3 and 7.3 +/- 0.4, respectively. At the 2-year follow-up, mean SNOT-20 and endoscopy scores improved to 7.7 +/- 0.6 and 2.1 +/- 0.4, respectively (p < 2.8 x 10(-10)). At 12-month follow-up, each individual symptom score decreased significantly. Overall, 10 patients failed RESS and required additional surgical intervention for an overall failure rate of 8.0 %. All patients who failed RESS had nasal polyposis. The authors concluded that revision FESS benefited patients who failed maximum medical therapy and prior sinus surgery for CRS by objective and subjective measures.

Le and colleagues (2008) stated that many studies have examined the prognostic factors affecting the success of ESS, and a history of previous ESS is generally regarded as a factor contributing to a poor surgical outcome. These investigators examined if previous ESS with polypectomy is associated with poor surgical outcomes after RESS by comparing the post-operative results between primary ESS (PESS) and RESS groups for CRS with nasal polyposis (CRSwNP). These researchers performed a retrospective analysis of prospectively collected data on 2 groups with a minimum 1-year follow-up: patients who underwent PESS with polypectomy (101 patients) and those who required RESS with polypectomy (24 patients). The extent of disease was compared using the Lund-MacKay scoring system, and the degree of polyposis was measured. Subjective patient symptom scores were recorded using the SNOT-20 questionnaire, and objective endoscopic physical findings were scored according to the parameters pre-operatively and 6 and 12 months post-operatively. The surgical outcomes of the PESS and RESS groups were compared using the SNOT-20 and nasal endoscopy scores. The Lund-Mackay score and degree of pre-operative polyposis did not differ statistically between the groups. The pre-operative mean SNOT-20 and nasal endoscopy scores were improved significantly at 6 and 12 months post-operatively, and the subjective and objective surgical outcomes of the 2 groups did not differ statistically. The need for additional medications during the follow-up period and the proportion of patients who required additional surgical intervention due to surgical failure was similar in both groups. The authors concluded that the findings of this study suggested that a history of ESS with polypectomy did not predict an unsuccessful surgical outcome after RESS and that ESS with polypectomy was a reliable and effective method for improving a patient's QOL regardless of primary or revision surgery.

Shen and co-workers (2011) stated that outcomes for RESS are rarely reported in relation to technique. These investigators documented the outcome of full-house FESS (FHF) (complete spheno-ethmoidectomy with Draf IIA frontal sinusotomy) for treatment of this recalcitrant group. A total of 21 patients with CRS having had at least 1 previous sinus surgery (mean of 2.14) underwent FHF, followed by post-operative nasal douching and oral antibiotics for 12 weeks. After a minimum 6-months follow-up, patients were asked to complete a 5-item Patient Response Score (PRS) (graded on a 6-point scale from 1 = completely improved to 6 = much worse). Objective measures collected included CT Lund MacKay score (L-M score, LMS), and endoscopic findings: mucosal swelling (MS) and mucopus (MP) (graded on a 4-point scale from 0 = none to 3 = severe). Patients were divided into 3 subgroups based on months of follow-up from surgery: 6 to 12, 12 to 18, and 18 to 24 months. There was no statistical difference in any outcome based on length of follow-up. Mean symptom outcome was reported as much improved (PRS = 1.9 ± 0.1). Both mucosal swelling and mucopus improved dramatically (2.48 versus 0.29, p < 0.001; 2.52 versus 0.29, p < 0.001, respectively); LMS also improved dramatically (11.52 versus 2.1, p < 0.001). Presence of nasal polyps did not affect any subjective or objective outcome. The authors concluded that marked improvements in symptoms and mucosal findings were consistently obtained with FHF between 6 and 24 months post-operatively.

Scope of Policy

This Clinical Policy Bulletin addresses sinus surgeries.

Medical Necessity

Aetna considers endoscopic sinus surgery (ESS) medically necessary for

any

of the following indications:

Allergic fungal rhino-sinusitis with objective evidence of disease by computerized tomographic (CT) imaging (see CT imaging requirements below)

Footnote1 *

;

or

Antrochoanal polyp documented by CT imaging

Footnote1 *

;

or

Cerebrospinal fluid (CSF) rhinorrhea or conditions in which there is a skull base defect;

or

Chronic rhino-sinusitis (longer than 12 continuous weeks) with nasal polyps (CRSwNP) with persistent symptoms that have failed maximal medical treatment (i.e., 6 weeks of saline irrigations, a course of at least 5 to 7 days of antibiotics if bacterial infection is suspected, and 6 weeks of intra-nasal corticosteroids) and objective evidence of disease by CT imaging

Footnote1 *

;

or

Chronic rhino-sinusitis (longer than 12 continuous weeks) without nasal polyps (CRSsNP) with persistent symptoms that have failed maximal medical treatment (i.e., 6 weeks of saline irrigations, a course of at least 5 to 7 days of antibiotics if bacterial infection is suspected, and 6 weeks of intra-nasal corticosteroids) and objective evidence of disease by CT imaging

Footnote1 *

;

or

Complications of sinusitis, including abscess (brain and sub-periosteal) and extension to adjacent structures (e.g., orbit, skull base);

or

Endonasal endoscopic hypophysectomy for pituitary adenoma;

or

Endoscopic orbital decompression for Graves ophthalmopathy, with or without optic nerve decompression;

or

Endoscopic partial ethmoidectomy for dacryocystorhinostomy;

or

Para-nasal sinus mucocele documented by CT scan (excluding benign, asymptomatic mucus retention cysts);

or

Recurrent acute rhino-sinusitis (RARS), when

all

of the following criteria are met:

Member has had 4 or more documented episodes of acute rhinosinusitis within 12 continuous months, with complete resolution of symptoms between each occurrence;

Dates of each episode of acute rhinosinusitis and types and durations of treatments for each episode should be documented in the medical record;

and

Episodes of acute rhinosinusitis have recurred despite maximal medical treatment:

Maximal medical treatment should include use of saline irrigations and intransal corticosteroids during acute episodes, plus antibiotics if bacterial infection is suspected);

and

Member has

either:

Objective evidence of outflow tract obstruction (not just narrowing/stenosis) or sinus infection by CT imaging

Footnote1 *

;

or

Evidence of rhinosinusitis by endoscopy documented during at least one acute episode;

or

Recurrent sinus barotrauma when conservative management (the use of oral decongestants and analgesics, and antibiotics if purulent nasal discharge is seen) has failed;

or

Silent sinus syndrome when endonasal endoscopic examination and orbital / paranasal CT scans have confirmed the diagnosis; or

Sino-nasal polyposis with nasal airway obstruction or sub-optimal asthma control (forced expiratory volume in 1 second (FEV1) of less than 80 % despite maximal medical treatment (i.e., saline irrigations, antibiotics if bacterial infection is suspected, and intra-nasal corticosteroids));

or

Suspected or known sino-nasal benign or malignant tumor (including but not limited to squamous cell, adenoid cystic or adenocarcinoma, inverted papilloma);

or

Unilateral pansinus opacification, symptomatic or asymptomatic, consistent with CRSsNP, CRSwNP, fungus ball, or neoplasm (e.g., sino-nasal inverted papilloma).

Note:

A trial of conservative treatment is not required when there is unilateral pansinus opacification.

Footnote1

* Abnormal CT findings include evidence of obstruction and infection. See

Appendix

for a list of abnormal CT findings. Documentation in the CT report must include a detailed description of the abnormal findings in each sinus, or quantification of the extent of disease as a percent of opacification, or the use of a scale such as the

Modified Lund-Mackay Scoring System

. T

he CT scan needs to be recent (within the last 12 months), and it must be taken at the completion of therapy. Electronic submission of CT scan images may be required

.

Aetna considers ESS experimental and investigational for all other indications.

Aetna considers revision ESS medically necessary when the following selection criteria are met:

At least 12 weeks have passed since previous ESS;

and

Chronic rhino-sinusitis has been present for at least 12 continuous weeks;

and

Failure of at least one 5 to 7 day course of antibiotics since the previous ESS;

and

Persistent objective evidence of sinus disease as documented by CT imaging.

Aetna considers revision ESS experimental and investigational for all other indications.

Aetna considers balloon sinus ostial dilation (balloon sinuplasty) of the frontal, maxillary or sphenoid sinuses medically necessary for the treatment of uncomplicated sinusitis without nasal polyposis (e.g., sinusitis confined to the paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures) when criteria are met (

see Appendix

).

Note

: Balloon sinus ostial dilatation is performed either as a stand-alone procedure or as part of functional endoscopic sinus surgery (FESS). However, when used with FESS in the same sinus cavity, it is considered to be an integral part of the primary procedure. Also

see Appendix

for "Table 1: Medical Necessity for Balloon Sinuplasty - Statements That Reached Consensus Patients Criteria" and "Table 2: Medical Necessity for Balloon Sinuplasty - Statements That Did Not Reach Consensus Patients Criteria" (from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)'s "Clinical consensus statement: Balloon dilation of the sinuses", Piccirillo et al, 2018).

Aetna considers image-guided ESS medically necessary for the following indications:

Benign and malignant sino-nasal neoplasms (e.g., sino-nasal inverted papilloma);

or

Cerebrospinal fluid rhinorrhea or conditions in which there is a skull base defect;

or

Disease abutting the skull base, orbit, optic nerve, or carotid artery;

or

Distorted sinus anatomy of development, post-operative, or traumatic origin (e.g., hypoplastic maxillary sinus, orbital fat and medial rectus herniation from a medial orbital blowout fracture, scarring or absence of normal surgical landmarks from prior sinus surgery; not an all-inclusive list);

or

Sino-nasal polyposis with nasal airway obstruction or sub-optimal asthma control;

or

Revision sinus surgery;

or

Sinus disease (as defined above) involving the frontal, posterior ethmoid, and sphenoid sinuses.

Aetna considers image-guided ESS experimental and investigational for all other indications.

Aetna considers up to 3 post-operative nasal endoscopies with debridement after sinus surgery medically necessary within the six weeks following sinus surgery.

Additional debridement procedures during that time, and debridement procedures performed outside of the 6 week postoperative period, are considered not medically necessary unless clinical circumstances are well-documented.

Additional debridements may be allowed if records are provided documenting any of the following (not an all-inclusive list):

persistent crusting

recurrent polyps

allergic mucin

retained fungal material

synechiae obstructing sinus ostia;

or

lateralized middle turbinate with ostial obstruction.

Aetna considers post-operative nasal endoscopy with debridement not medically necessary after nasal surgery (e.g., septoplasty, turbinectomy) and after balloon sinuplasty.

Aetna considers diagnostic endoscopy with puncture of the sphenoid and/or maxillary sinuses medically necessary when abnormal findings on CT scanning indicate the need for an invasive diagnostic procedure.

Examples include tumor/mass and multiple sinus symptoms (nasal obstruction, anterior or posterior mucopurulent (foul) drainage, facial pain, pressure, headache (when other causes have been ruled out) and/ or fullness over the affected sinus, decreased sense of smell).

Aetna considers these procedures not medically necessary when these criteria are not met.

Notes

: For purposes of this policy, Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram). If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement. The surgeon should discuss the disagreement with the provider who did the official interpretation, and there should also be a written addendum to the official report indicating agreement or disagreement with the operating surgeon. The imaging should be performed within the past year, or after the onset of the current constellation of symptoms or any relevant surgical procedures, whichever is sooner. A reading by a radiologist is required to validate any changes to the complex imaging report that occur after the report is submitted to Aetna.

Experimental and Investigational

Balloon ostial dilation experimental and investigational for

any

of the following indications (not an all-inclusive list):

Antro-choanal polyp

Bony dysplasia (i.e., including but not limited to fibrous dysplasia, Paget’s disease)

Extensive fungal sinusitis

History of failed balloon procedure in the sinus to be treated

Isolated ethmoid sinus disease

Mucocele causing sinusitis

Nasal polyposis (grade 2 or greater)

Recurrent sinus barotrauma

Repeat balloon procedure in any of the sinuses

Samter’s triad (aspirin sensitivity)

Severe sinusitis secondary to autoimmune or connective tissue disorders (i.e., including, but not limited to, sarcoidosis, granulomatosis with polyangiitis (PGA))

Severe sinusitis secondary to ciliary dysfunction, (i.e., including but not limited to, cystic fibrosis, Kartagener’s syndrome)

Suppurative or non-suppurative complications of sinusitis including extension to adjacent structures such as the orbit or central nervous system

Suspected or known sino-nasal benign or malignant tumor (including but not limited to squamous cell, adenoid cystic or adenocarcinoma, inverted papilloma)

Unilateral pansinus opacification.