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:

• SURG 00089 Balloon Sinus Ostial Dilation
• SURG.00096 Surgical Treatment of Migraine Headaches

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:

• Suspected tumor seen on imaging, physical examination, or endoscopy
• Suppurative (pus forming) complications, including  but are not limited to:
  • Subperiosteal abscess
  • Brain abscess
• Chronic polyposis with symptoms unresponsive to medical therapy
• Allergic fungal sinusitis, as indicated by all of the following:
  • Nasal polyposis; and
  • Positive CT findings; and
  • Eosinophilic mucus.
• Mucocele
• Recurrent sinusitis that triggers or aggravates pulmonary disease, such as asthma or cystic fibrosis
• Uncomplicated sinusitis (i.e., sinusitis confined to the paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures) and all of the following:
  • Either four or more documented episodes of acute rhinosinusitis (i.e., less than 4 weeks duration) in one year, or chronic sinusitis (i.e., greater than 12 weeks duration) that interferes with lifestyle; and
  • Maximal medical therapy has been attempted, as indicated by all of the following:
    • Antibiotic therapy for at least 4 weeks; and
    • Trial of inhaled steroids; and
    • Nasal lavage; and
    • Allergy assessment.
• Abnormal findings from diagnostic work-up, as indicated by any one of the following:
  • Findings suggestive of obstruction or active infection on CT; or
  • Significant obstructive symptoms due to polyposis that persist or recur after oral and topical corticosteroid treatment; or
  • Nasal endoscopy findings suggestive of significant disease.
• Fungal mycetoma
• Failed other sinus surgery
• Cerebrospinal fluid rhinorrhea
• Encephalocele
• Posterior epistaxis (relative indication)
• Persistent facial pain after other causes ruled out (relative indication)

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

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

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.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  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.

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

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).

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.

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. Hamilos DL. Chronic sinusitis. J Allergy Clin Immunol. 2000; 106(2):213-227.
7. 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.
8. 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.
9. 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.
10. Lieser JD, Derkay CS. Pediatric sinusitis: when do we operate? Curr Opin Otolaryngol Head Neck Surg. 2005. 13(1):60–66.
11. Luong A, Marple BF. Sinus surgery: Indications and techniques. Clin Rev Allergy Immunol. 2006; 30(3):217-222.
12. Manning S. Surgical intervention for sinusitis in children. Curr Allergy Asthma Rep. 2001; 1(3):289-296.
13. 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
14. Orlandi RR, Kennedy DW. Surgical management of rhinosinusitis. Am J Med Sci. 1998; 316(1):29-38.
15. 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.
16. 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.
17. 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.
18. 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. Khalil HS, Nunez DA. Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database SystRev. 2006; 3:CD004458.

FESS
Functional Endoscopic Sinus Surgery
Mucocele
Nasal Polyposis
Sinusitis