Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-57 Diagnostic Nasal Endoscopy Form



Initial Diagnostic Nasal Endoscopy

Indications

(551935) Is the diagnostic nasal endoscopy for initial evaluation and visualization of nasal anatomy due to symptoms suggestive of nasal or sinus origin? 
(551936) Does physical examination not provide sufficient clinical information to establish a diagnosis? 
(551937) Is there suspicion of nasal obstruction not due to septal deviation that is refractory to medical therapy? 
(551938) Is there suspicion or monitoring needs for chronic sinusitis? 
(551939) Is there a need to monitor for recurrent nasal polyps? 
(551940) Is it required for the initial diagnosis or interval surveillance of sinonasal neoplasms? 
(551941) Is it to evaluate clear rhinorrhea when cerebrospinal fluid leak is suspected? 
(551942) Is it to assess facial pain suggestive of rhinogenic origin? 
(551943) Is it for a patient experiencing recurrent or single severe posterior nasal epistaxis? 
(551944) Is the procedure for endoscopically guided cultures in case of recurrent sinusitis that has failed antibiotic therapy, or if antibiotic therapy is limited by drug allergies? 

Contraindications

(551945) Is the nasal endoscopy being used as a screening tool for an asymptomatic individual? 

Repeat Diagnostic Nasal Endoscopy

Notes: A repeat diagnostic nasal endoscopy may be considered medically necessary depending on the response to initial treatment.

Indications

(551946) Is the repeat diagnostic nasal endoscopy indicated because the patient's symptoms have not improved or worsened following treatment? 

Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the diagnostic use of nasal endoscopy in the office or outpatient setting. The nasal endoscope is a thin, rigid or flexible tube with an attached light source, which is passed through the nostril to evaluate the deeper internal nasal anatomy, central airway and lateral or posterior aspects of the nasal cavity and sinuses. This procedure is used when an evaluation using a nasal speculum is not adequate.

Notes:

  • Please see the following documents for related information:
    • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS): for the endoscopic treatment of nasal or sinus conditions
    • CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
  • This document does not address diagnostic nasopharyngoscopy

Clinical Indications

Medically Necessary:

The use of diagnostic nasal endoscopy is considered medically necessary for the initial evaluation and visualization of the nasal anatomy when there are symptoms suggestive of nasal or sinus origin and physical examination (including a nasal speculum evaluation) does not provide sufficient clinical information to establish a diagnosis. This includes, but is not limited to:

  1. Evaluate chronic sinonasal symptoms when there is a suspicion of:
    1. Nasal obstruction not due to septal deviation that is refractory to medical therapy; or
    2. Chronic sinusitis
  2. Monitor for recurrent nasal polyps
  3. Initial diagnosis or interval surveillance of sinonasal neoplasms
  4. Evaluate clear rhinorrhea if cerebrospinal fluid leak is suspected
  5. Assessment of facial pain suggestive of rhinogenic origin
  6. Evaluation of recurrent or single severe posterior nasal epistaxis
  7. Endoscopically guided cultures for recurrent sinusitis which has failed empiric antibiotic therapy or if empiric antibiotic therapy is limited by drug allergies

A repeat diagnostic nasal endoscopy is considered medically necessary when the symptoms do not improve or worsen following treatment (medical/surgical).

Not Medically Necessary:

Nasal endoscopy is considered not medically necessary when the criteria above have not been met, and for all other indications, including as a screening tool in the evaluation of an asymptomatic individual.