Clinical UM Guideline


Subject:Functional Endoscopic Sinus Surgery (FESS)
Guideline #:  CG-SURG-24Current Effective Date:  10/08/2013
Status:RevisedLast Review Date:  08/08/2013

Description

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 document for related information:

Clinical Indications

Medically Necessary:

Functional endoscopic sinus surgery (FESS) is considered medically necessary for the treatment of sinusitis, polyposis, or sinus tumor when any one of the following circumstances is present:

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

Not Medically Necessary: 

Functional endoscopic sinus surgery is considered not medically necessary for the treatment of sinusitis, polyposis, sinus tumor, or any other condition 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.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
31237Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [when specified as debridement following sinus surgery]
31254Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
31255Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)
31256Nasal/sinus endoscopy, surgical, with maxillary antrostomy
31267Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
31276Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus
31287Nasal/sinus endoscopy, surgical, with sphenoidotomy
31288Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
  
HCPCS 
S2342Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral
  
ICD-9 Procedure 
22.2Intranasal antrotomy
  
ICD-9 Diagnosis 
039.0-039.9Actinomycotic infections (actinomycotic mycetoma)
212.0Benign neoplasm of nasal cavities, middle ear, and accessory sinuses
235.9Neoplasm of uncertain behavior of other and unspecified respiratory organs (accessory sinuses)
239.1Neoplasms of unspecified nature, respiratory system
325Phlebitis and thrombophlebitis of intracranial venous sinuses
461.0-461.9Acute sinusitis
471.0-471.9Nasal polyps
473.0-473.9Chronic sinusitis
784.7Epistaxis
V58.49Other specified aftercare following surgery
  
ICD-10 ProcedureICD-10-PCS draft codes; effective 10/01/2014:
095P4ZZ-095X4ZZDestruction of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal ethmoid or sphenoid; includes codes 095P4ZZ, 095Q4ZZ, 095R4ZZ, 095S4ZZ, 095T4ZZ, 095U4ZZ, 095V4ZZ, 095W4ZZ, 095X4ZZ]
099P40Z-099X4ZZDrainage of sinus, percutaneous endoscopic approach [with or without device, accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 099P40Z, 099P4ZZ, 099Q40Z, 099Q4ZZ, 099R40Z, 099R4ZZ, 099S40Z, 099S4ZZ, 099T40Z, 099T4ZZ, 099U40Z, 099U4ZZ, 099V40Z, 099V4ZZ, 099W40Z, 099W4ZZ, 099X40Z, 099X4ZZ]
09BP4ZZ-09BX4ZZExcision of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09BP4ZZ, 09BQ4ZZ, 09BR4ZZ, 09BS4ZZ, 09BT4ZZ, 09BU4ZZ, 09BV4ZZ, 09BW4ZZ, 09BX4ZZ]
09CP4ZZ-09CX4ZZExtirpation of matter from sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09CP4ZZ, 09CQ4ZZ, 09CR4ZZ, 09CS4ZZ, 09CT4ZZ, 09CU4ZZ, 09CV4ZZ, 09CW4ZZ, 09CX4ZZ]
09DP4ZZ-09DX4ZZExtraction of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09DP4ZZ, 09DQ4ZZ, 09DR4ZZ, 09DS4ZZ, 09DT4ZZ, 09DU4ZZ, 09DV4ZZ, 09DW4ZZ, 09DX4ZZ]
09JY4ZZInspection of sinus, percutaneous endoscopic approach
09NP4ZZ-09NX4ZZRelease sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09NP4ZZ, 09NQ4ZZ, 09NR4ZZ, 09NS4ZZ, 09NT4ZZ, 09NU4ZZ, 09NV4ZZ, 09NW4ZZ, 09NX4ZZ]
09QP4ZZ-09QX4ZZRepair sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09QP4ZZ, 09QQ4ZZ, 09QR4ZZ, 09QS4ZZ, 09QT4ZZ, 09QU4ZZ, 09QV4ZZ, 09QW4ZZ, 09QX4ZZ]
09TP4ZZ-09TX4ZZResection of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09TP4ZZ, 09TQ4ZZ, 09TR4ZZ, 09TS4ZZ, 09TT4ZZ, 09TU4ZZ, 09TV4ZZ, 09TW4ZZ, 09TX4ZZ]
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
A42.0-A42.9Actinomycosis
D14.0Benign neoplasm of nasal cavities, middle ear, and accessory sinuses
D38.5Neoplasm of uncertain behavior of other respiratory organs (accessory sinuses)
D38.6Neoplasm of uncertain behavior of respiratory organ, unspecified
G08Intracranial and intraspinal phlebitis and thrombophlebitis
J01.00- J01.91Acute sinusitis
J32.0-J32.9Chronic sinusitis
J33.0-J33.9Nasal polyps
R04.0Epistaxis
Z48.89Encounter for other specified surgical aftercare
  
Discussion/General Information

Functional endoscopic sinus surgery (FESS) is the most commonly used surgical technique to treat medically unresponsive chronic sinusitis and other serious conditions of the nasal sinuses that result in impaired sinus drainage.  FESS utilizes small fiberoptic tools to access the nasal sinuses through the nasal opening to remove diseased tissue and bone, resulting in opened sinus passageways, improved mucus drainage, and promotion of healthy tissue growth.

Prior to the creation and adoption of FESS, the standard treatment method involved the creation of a surgical opening in the upper jaw above the front teeth.  The use of FESS allows for a much less invasive and traumatic procedure, resulting in shorter surgery and healing times, less postoperative discomfort, and fewer surgical complications.

Despite having been widely adopted as the standard of care, only a few controlled trials evaluating the use of FESS for various conditions are currently available in the medical literature. One randomized controlled trial by Blomqvist (2001) compared medical treatment for nasal polyps with surgery followed by medical treatment in 32 subjects with a follow-up of one year.  The authors reported that surgery reduced the polyp score and improved nasal obstruction symptoms, but did not help with hyposmia (reduced sense of smell).  Another study by Penttila (1997) reported the results of a randomized study comparing FESS vs. the Caldwell-Luc (C-L) open procedure for the treatment of chronic maxillary sinusitis.  Follow-up ranged from 5 to 9 years with 128 individuals responding.  The authors report that the outcomes for the FESS group were approximately equivalent to that in the C-L group.

A prospective, randomized, controlled trial of medical vs. surgical treatment of polypoid and nonpolypoid chronic rhinosinusitis (CRS) is described by Ragab and colleagues (2004).  In this study ninety people with CRS were randomized to either medical or surgical therapy with FESS.  The study found that both the medical and surgical treatments for CRS significantly improved almost all subjective and objective parameters of CRS with no significant difference being found between the two groups.  The authors conclude that CRS should initially be treated with maximal medical therapy (e.g., antibiotics and topical steroids), with surgical treatment being reserved for cases refractory to medical therapy.

Finally, a Cochrane review of FESS for the indication of chronic rhinosinusitis from May 2006 concluded:

The evidence available does not demonstrate that FESS, as practiced in the included trials, is superior to medical treatment with or without sinus irrigation in patients with chronic rhinosinusitis.  There were no major complications in any of the included trials and FESS appears to be a safe procedure.  More randomised controlled trials comparing FESS with medical and other treatments, with long-term follow up, are required.

Although the literature-based evidence addressing FESS is limited, the clinical experience over the past decade has demonstrated the safety and efficacy of this procedure compared to more invasive techniques

There is limited literature addressing nasal or sinus debridement after FESS surgery.  A small study found no significant benefit from debridement (Nilssen, 2002), and another found only minor symptomatic benefit when debridement was performed during the first postoperative week (Kemppainen, 2008).  Another study found that debridement significantly reduces crusting and postoperative adhesions as compared with saline irrigation, but was associated with significantly more postoperative pain (Bugten, 2006).  The authors reported that at 12 weeks after surgery there were no significant differences between individuals receiving or not receiving debridement in terms of polyps, edema, crusting, and discharge.  A very small randomized trial suggested that one-week intervals were optimal for performing debridement, which the authors indicate is currently most often performed in a large number of clinical settings (Lee, 2008).  A study by Fishman and colleagues conducted a prospective, randomized controlled, single-blinded, within-subject trial involving 24 subjects who underwent FESS and were followed for three months posoperatively (2011).  Each subject had frequent endoscopic cleaning on one side versus minimal intervention on the other in the early post-operative period.  The authors reported that there was no overall statistically significant difference between the two groups (p = 0.37).  A post-hoc subgroup analysis revealed a significant effect of regular suction clearance on adhesions at three months (p = 0.048), but not on edema, polyps, granulation, discharge or crusting.

Postoperative debridement may need to occur for longer periods in some individuals with conditions that may lead to the development of complications.  Such individuals include those severe resistant nasal polyposis, neoplasm, or allergic fungal sinusitis.  However, even in these individuals, debridement should be prompted by symptoms which arise as a consequence of the more extensive surgery or underlying disease.  There is no evidence that debridement absent symptoms, even with these risk factors for complications after FESS, is associated with improved outcomes.

References

Peer Reviewed Publications:

  1. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology.  Otolaryngol Head Neck Surg. 2003; 129(3 Suppl):S1-32.
  2. Blomqvist EH, Lundblad L, Anggard A, et al. A randomized controlled study evaluating medical treatment versus surgical treatment in addition to medical treatment of nasal polyposis. J Allergy Clin Immunol. 2001; 107(2):224-228.
  3. Bugten V, Norgard S, Steinsvag S. The effects of debridement after endoscopic sinus surgery.  Laryngoscope.  2006; 116(11):2037-2043.                                       
  4. Busaba NY, Kieff D. Endoscopic sinus surgery for inflammatory maxillary sinus disease. Laryngoscope. 2002; 112(8 Pt 1):1378-1383.
  5. Ehnhage A, Olsson P, Kölbeck KG, et al. Functional endoscopic sinus surgery improved asthma symptoms as well as PEFR and olfaction in patients with nasal polyposis. Allergy. 2009; 64(5):762-769.
  6. Fishman JM, Sood S, Chaudhari M, et al.  Prospective, randomised controlled trial comparing intense endoscopic cleaning versus minimal intervention in the early post-operative period following functional endoscopic sinus surgery. J Laryngol Otol. 2011; 125(6):585-589.
  7. Hamilos DL. Chronic sinusitis. J Allergy Clin Immunol. 2000; 106(2):213-227.
  8. Kemppainen T, Seppä J, Tuomilehto H, et al. Repeated early debridement does not provide significant symptomatic benefit after ESS. Rhinology. 2008; 46(3):238-242.
  9. Kuhn FA, Javer AR. Allergic fungal rhinosinusitis: perioperative management, prevention of recurrence, and role of steroids and antifungal agents. Otolaryngol Clin North Am. 2000; 33(2):419-433.
  10. Lee JY, Byun JY. Relationship between the frequency of postoperative debridement and patient discomfort, healing period, surgical outcomes, and compliance after endoscopic sinus surgery. Laryngoscope. 2008; 118(10):1868-1872.
  11. Lieser JD, Derkay CS. Pediatric sinusitis: when do we operate? Curr Opin Otolaryngol Head Neck Surg. 2005. 13(1):60–66.
  12. Luong A, Marple BF. Sinus surgery: indications and techniques. Clin Rev Allergy Immunol. 2006; 30(3):217-222.
  13. Manning S. Surgical intervention for sinusitis in children. Curr Allergy Asthma Rep. 2001; 1(3):289-296.
  14. Nilssen E, Wardrop P, El-Hakim H, et al. A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement. J Laryngol Otol. 2002; 116(2):108-111
  15. Orlandi RR, Kennedy DW. Surgical management of rhinosinusitis. Am J Med Sci. 1998; 316(1):29-38.
  16. Penttila MA, Rautiainen ME, Pukander JS, Karma PH.   Endoscopic versus Caldwell-Luc approach in chronic maxillary sinusitis: comparison of symptoms at one-year follow-up. Rhinology. 1994; 32(4):161-165.
  17. Penttila MA, Rautiainen ME, Pukander JS, Kataja M.   Functional vs. radical maxillary surgery. Failures after functional endoscopic sinus surgery. Acta Otolaryngol Suppl. 1997; 529:173-176.
  18. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope. 2004; 114(5):923–930.
  19. Seiden AM, Stankiewicz JA. Frontal sinus surgery: the state of the art. Am J Otolaryngol. 1998; 19(3):183-193.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Academy of Otolaryngology-Head and Neck Surgery. Clinical Indicators: Endoscopic Sinus Surgery, Pediatric.  2012. Available at: http://www.entnet.org/Practice/upload/Endoscopic-Debridement-CI.pdf. Accessed on June 10, 2013.
  2. American Academy of Otolaryngology-Head and Neck Surgery. Clinical Indicators: Endoscopic Sinus Surgery, Adult. 2012. Available at: http://www.entnet.org/Practice/upload/Endoscopic-Sinus-Surgery_Adult_-CI_May-2012.pdf. Accessed on June 10, 2013.
  3. American Academy of Otolaryngology-Head and Neck Surgery. Clinical Indicators Endoscopic Debridement. 2010. Available at: http://www.entnet.org/Practice/upload/Endoscopic-Debridement-CI.pdf.  Accessed on: June 10, 2013.
  4. Khalil HS, Nunez DA. Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev. 2006; 3:CD004458.
Index

FESS
Functional Endoscopic Sinus Surgery
Mucocele
Nasal Polyposis
Sinusitis

History
StatusDateAction
Revised08/08/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  Clarified medically necessary criteria regarding CT findings for uncomplicated sinusitis and allergy assessment. Updated Coding and Reference sections. 
 07/01/2013Updated Coding section to remove CPT 31240 (not applicable).
Revised08/09/2012MPTAC review. Revised mucocele indication in MN statement to add "causing chronic sinusitis".  Added "Cavernous sinus thrombosis caused by chronic sinusitis" to MN statement.  Updated Coding and Reference sections. 
Revised05/10/2012MPTAC review. Revised statement regarding uncomplicated sinusitis.  Revision of debridement statement regarding symptoms of nasal obstruction.
Revised08/18/2011MPTAC review. Added language to not medically necessary section regarding the use of FESS for all other indications.
Revised11/18/2010MPTAC review. Added medically necessary and not medically necessary statements regarding postoperative debridement following FESS.  Updated rationale and references.
Reviewed08/19/2010Medical Policy & Technology Assessment Committee (MPTAC) review.  Updated Reference section
Reviewed08/27/2009MPTAC review. No change to guideline position. Updated Reference section.
Reviewed08/28/2008MPTAC review. No change to guideline position.
Reviewed08/23/2007MPTAC review. No change to guideline position.
New09/14/2006MPTAC initial guideline development.