This is a patient with a nasal chrondosarcoma. Treatment has included resection and proton beam radiation. On examination the patient was noted to have a moderate amount of crusting and obstruction in the drainage of the sinuses. CPT code 31237 Nasal/sinus endoscopy surgical; with biopsy, polpectomy or debridement (separate procedure) was denied as not medically necessary because the procedure was done beyond the 30 days from the original surgery. At issue is the medical necessity of the requested procedure.
The health plan's determination is overturned.
The patient's prior surgery (resection of nasal chondrosarcoma) results in recurrent nasal crusting (requiring debridement). Documentation of the patient's clinic visit did show crusting in the nasal cavity that obstructed the paranasal sinuses. The current literature does support the need to remove crusting to improve mucocillary clearance. There is literature to support frequent debridements for sinonasal obstruction. Research by Lee and Byun 2008 supported this and added that patient individualization should be taken into account depending on the extent of surgery and healing progress. As in the case of this patient, the surgeon recognized the need for the crusting removal.