Diagnosis: Chronic running sinusitis and rhinitis associated with headache

Treatment: Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT

The insurer denied coverage for Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT.

The denial is overturned.

This is a female patient with a long history of chronic running sinusitis and rhinitis associated with headache. The patient's sinus disease had been continuously documented in her medical records. There are numerous notes concerning this patient's nasal edema, nasal congestion, purulent discharge, nasal stuffiness, and headaches. The patient was continuously treated with Depo Medrol and Allegra. The patient was seen for allergy and has been continuously under the care of the allergists. The patient has undergone desensitization and placed on various medications during this period including Singulair tablets, nasal saline and fluticasone propionate spray. The patient's otolaryngologist documented that when he performed the nasal endoscopy and used topical anesthetic mixed with decongestant, the patient's headaches completely disappeared.

Peer reviewed literature supports the diagnosis of contact point headache noted by the responsiveness to local anesthesia, and the role of Functional Sinus Surgery to cure most of these patients. The guidelines of the American Academy of Otolaryngology - Head Neck Surgery States that adults with possible sinusitis for greater than 12 weeks, who had signs and symptoms of chronic sinusitis, with documenting sound nasal inflammation, who have undergone saline and/or topical intranasal corticosteroids, and have had allergy and immune function testing can undergo surgical management.

In this case, the patient fulfills the clinical guideline for Functional Sinus Surgery. There is documentation that when a portion of the patient's intranasal cavity was anesthetized, her headache disappeared. In addition, for at least 8 years, the patient had been taking appropriate medications and had a complete allergic workup for chronic sinusitis. Thus, the Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT was considered medically necessary for this patient as the patient fulfilled all the criteria for the surgery based upon peer-reviewed literature on contact point sinus headache; for instance, the patient's headache disappeared when part of the nose was anesthetized and with chronic rhino sinusitis, for which the patient had been cared for appropriately over 12 years using various medications, steroids, and allergic desensitization.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for Functional Endoscopic Sinus Surgery (FESS), codes 31254-LT/RT and 31256-LT/RT is substantiated. The insurer's denial should be overturned.