Medical Coverage Policy Effective Date ............................................. 7/10/2021 Next Review Date ....................................... 3/15/2022 Coverage Policy Number .................................. 0554 Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy Table of Contents Related Coverage Resources Overview .............................................................. 1 Balloon Sinus Ostial Dilation for Chronic Sinusitis and Coverage Policy ................................................... 2 Eustachian Tube Dilation General Background ............................................ 3 Drug-Eluting Devices for Use Following Endoscopic Medicare Coverage Determinations .................. 10 Sinus Surgery Coding/Billing Information .................................. 10 Rhinoplasty, Vestibular Stenosis Repair and Septoplasty References ........................................................ 28 INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations. Overview This Coverage Policy addresses diagnostic nasal/sinus endoscopy, functional endoscopic sinus surgery (FESS) and turbinectomy procedures. Endoscopy is the insertion of a thin tube directly into an opening in the body, or less frequently through a small incision to observe an internal organ or tissue in detail. Such procedures are considered minimally invasive. Diagnostic nasal/sinus endoscopy is used to look at the nasal and sinus passages when external assessment does not provide sufficient information. FESS is most commonly performed and medically appropriate for inflammatory and infectious sinus disease. Turbinectomy may be a medically appropriate option to clear an obstruction of the turbinate(s), when conservative medical treatment such as nasal steroids, has failed. Medically appropriate indications are informed by published peer-reviewed evidence and professional society guidelines. For indications that are considered medically appropriate for diagnostic nasal endoscopy, FESS and turbinectomy please refer to the coding/billing information section. Page 1 of 31 Medical Coverage Policy: 0554 Coverage Policy Diagnostic nasal/sinus endoscopy, functional endoscopic sinus surgery and turbinectomy (see CPT® code lists below) are considered medically necessary when the associated signs and symptoms or diagnoses are listed in the coding/billing information section for ANY of the following: • diagnostic nasal/sinus endoscopy: CPT® Code Description Code 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31233 Nasal/sinus endoscopy, diagnostic; with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) 31235 Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) • functional endoscopic sinus surgery (FESS): CPT® Code Description Code 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection 31253 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed 31254 Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) 31255 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; 31257 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy 31259 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 31276 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus • turbinectomy: CPT® Code Description Code 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial 30802 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) 30130 Excision inferior turbinate, partial or complete, any method 30140 Submucous resection inferior turbinate, partial or complete, any method Page 2 of 31 Medical Coverage Policy: 0554 Diagnostic nasal/sinus endoscopy, functional endoscopic sinus surgery and turbinectomy procedures discussed within the scope of this Coverage Policy are considered not medically necessary for any other indication. General Background Diagnostic Nasal/Sinus Endoscopy Diagnostic nasal/sinus endoscopy is an established method of assessing the nasal and sinus passages. It is a part of the rhinologic examination in the evaluation of nasal mucosa, sinonasal anatomy, and nasal pathology and is often performed in an otorhinolaryngology office. It allows for an objective, detailed examination by magnification of the nasal and sinus cavities not possible by standard examination such as anterior rhinoscopy using headlight or head mirror (Maru and Gupta, 2014). Nasal /sinus endoscopy involves the use of a fiberoptic endoscope with a tiny camera and light which is inserted into the nose to view the nasal cavity and/or sinuses. The procedure can be used alone or with the introduction of other instruments to detect various sinonasal pathologies as well as anatomical variations (Maru and Gupta, 2014). Use of an endoscopic approach has the potential to decrease surgery and healing times as well as postoperative discomfort. Medically appropriate indications are the evaluation of nasal blockage, nasal and sinus infection (rhinosinusitis), osteomyelitis, sinusitis, nasal polyps, mucocele nasal tumors, nasal bleeding, anosmia, hyposmia, parosmia, rhinorrhea, obstructive sleep apnea, choanal atresia, fracture, foreign body, barotrauma and cerebrospinal leak. Literature Review According to the American Rhinologic Society (2019) endoscopic evaluation and endoscopic surgery have both been recognized as accepted modalities of diagnosis and treatment of sinonasal disorders. Regarding diagnostic nasal endoscopy the Society notes that the procedure is typically performed in the office setting, although it can be performed in the hospital outpatient setting. Common indications for diagnostic nasal endoscopy include but are not limited to: • evaluation of chronic sinonasal symptoms; • assessment of interval response to medical or surgical therapy • monitoring for recurrence of sinusitis and/or nasal polyps; • evaluation and management of epistaxis; • performance of endoscopically guided cultures; • assessment of facial pain suggestive of nasal origin; • evaluation of clear rhinorrhea suggestive of cerebrospinal fluid leak; • performance of initial diagnosis and interval surveillance for sinonasal neoplasms; or • evaluation of smell disorders. Functional Endoscopic Sinus Surgery (FESS) Medical therapy is generally the initial approach to treatment of sinonasal disease. If medical therapy is ineffective, a direct inspection of the patient's nasal anatomy with a nasal endoscope