The use of functional endoscopic sinus surgery is considered medically necessary for individuals with chronic rhinosinusitis when the following criteria are present:
Chronic rhinosinusitis that negatively impacts quality of life, characterized by at least 2 of the following, at least 1 of which is (a) or (b), present for at least 12 continuous weeks:
Mucopurulent nasal drainage (anterior, posterior, or both);
Nasal obstruction (congestion);
Facial pain-pressure-fullness;
Decreased sense of smell.
AND
Optimal medical therapy has been attempted and failed, as indicated by all of the following:
Allergy evaluation, education, and optimal treatment when indicated;
Two 10 day courses of antibiotics or 1 prolonged course of oral antibiotic for at least 21 days;
Decongestants when indicated;
Topical and/or systemic corticosteroids for at least 8 weeks;
Saline nasal irrigations for at least 8 consecutive weeks;
Treatment of rhinitis medicamentosa (rebound nasal congestion due to extended use of topical decongestants), when present;
Education on environmental irritants including tobacco smoke.
AND
Clinical and radiographic documentation of persistent inflammation following optimal medical therapy (see Policy Guidelines).
AND
There are no serious urgent complications of acute sinusitis that would suggest orbital cellulitis or abscess, intracranial extension of infection, or other complication that would require urgent or emergent surgery such that “appropriate medical therapy” for 8 weeks would not be appropriate.
The use of functional endoscopic sinus surgery is considered investigational for the treatment of chronic rhinosinusitis when the above criteria are not met.
