Anthem Blue Cross Connecticut CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS) Form

This document addresses the use of functional endoscopic sinus surgery (FESS), an endoscopic surgical procedure used to treat various conditions of the nasal sinuses, including but not limited to chronic sinusitis.

Note: Please see the following documents for related information:

• CG-SURG-18 Septoplasty
• CG-SURG-73 Balloon Sinus Ostial Dilation
• SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
• MED.00091 Rhinophototherapy
• SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Clinical Indications

Medically Necessary:

Functional endoscopic sinus surgery (FESS) is considered medically necessary when any one of the following circumstances is present:

1. Suspected tumor seen on imaging, physical examination, or endoscopy; or
2. Suppurative (pus forming) complications, including but are not limited to:
   1. Subperiosteal abscess; or
   2. Brain abscess; or
3. Chronic polyposis with symptoms unresponsive to medical therapy; or
4. Allergic fungal sinusitis; or
5. Mucocele causing chronic sinusitis; or
6. Recurrent sinusitis that triggers or aggravates pulmonary disease, such as asthma or cystic fibrosis; or
7. Uncomplicated sinusitis (for example, sinusitis confined to the paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures) and all (1, 2, and 3) of the following:
   1. Either of the following:
      1. Four or more documented episodes of acute rhinosinusitis (for example, less than 4 weeks duration) in one year; or
      2. Chronic sinusitis (for example, greater than 12 weeks duration) that interferes with lifestyle; and
   2. Maximal medical therapy has been attempted, as indicated by all of the following:
      1. Antibiotic therapy; and
      2. Trial of inhaled steroids; and
      3. Nasal lavage; and
      4. Allergy testing (if symptoms are consistent with allergic rhinitis and have not responded to appropriate environmental controls and pharmacotherapy [antihistamines, intranasal corticosteroids, leukotriene antagonists, etc.]); and
   3. Abnormal findings from diagnostic work-up, as indicated by any one of the following:
      1. CT findings suggestive of obstruction or infection for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitis, or diffuse opacification; or
      2. Nasal endoscopy findings suggestive of significant disease; or
      3. Physical exam findings suggestive of chronic/recurrent disease (for example, mucopurulence, erythema, edema, inflammation); or
8. Fungal mycetoma; or
9. Persistent sinus symptoms following any prior sinus surgery; or
10. Cerebrospinal fluid rhinorrhea; or
11. Encephalocele; or
12. Posterior epistaxis (relative indication); or
13. Persistent facial pain after other causes ruled out (relative indication); or
14. Cavernous sinus thrombosis caused by chronic sinusitis.

Nasal or sinus cavity debridement following FESS is considered medically necessary for any of the following circumstances:

1. Twice during the first 30 days postoperatively; or
2. Postoperative loss of vision or double vision; or
3. Evidence of cerebrospinal fluid leak such as rhinorrhea; or
4. When prompted by physical obstruction of the sinus opening related to:
   1. Nasal polyps unresponsive to oral or nasal steroids; or
   2. Documented presence of papilloma, carcinoma or other neoplasm; or
   3. Allergic fungal sinusitis.

Not Medically Necessary:

Functional endoscopic sinus surgery is considered not medically necessary when the criteria above are not met.

Nasal or sinus cavity debridement following FESS is considered not medically necessary when criteria above are not met, including additional post-surgical debridement beyond 30 days post-procedure.