BlueCross and BlueShield of Montana Medical Policy/Codes
Ultrasound for the Evaluation of Paranasal Sinuses
Chapter: Radiology
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Ultrasound for the evaluation of paranasal sinuses has been proposed as a diagnostic procedure used to confirm the diagnosis of and the presence of sinus fluid in cases of sinusitis in demonstrating mucosal wall thickening, focal soft tissue masses, and complex collections. Ultrasound is non-ionizing and non-invasive when compared to the conventional diagnostic alternatives of radiography or sinuscopy for sinus evaluation.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Not Medically Necessary

Ultrasound in the evaluation of paranasal sinuses is considered not medically necessary.

Rationale

The diagnosis and management of disorders of the paranasal sinuses are the typical focus of a general otolaryngologist’s practice. While most cases can be managed empirically, imaging of the sinuses may be required for equivocal or atypical presentations. Imaging options include plain film radiography, computed tomography (CT), magnetic resonance imaging (MRI), or ultrasonography, with CT scans considered the gold standard. Ultrasonography has been proposed as a convenient office-based alternative with the added advantage of low radiation exposure and a better discriminator between mucosal thickening and fluid retention. However, a review of the English language literature did not identify any published studies that adequately explored the diagnostic capabilities of ultrasonography in comparison to other imaging options. For example, in a 1997 study, Haapaniemi and colleagues performed plain film radiography and ultrasound of the maxillary sinus on a series of 663 unselected school children ages 7 to 14 years old. (1) The plain film radiograph was considered the gold standard, and sinusitis was suggested if marked mucosal thickening or the presence of a fluid level or cyst was present. On ultrasonography, the presence of a back wall echo was considered an abnormal finding, suggesting chronic sinusitis. Discrepancies between the 2 studies occurred in 74 studies; the presence of a back wall echo on ultrasonography predicted positive x-ray finding with a sensitivity of 69%, while a negative ultrasonography predicted the absence of chronic sinusitis with a specificity of 98%. However, the results of these studies were not correlated with the children’s symptoms, and considering that the interpretation of plain film x-rays, particularly the evaluation of mucosal thickening, has been controversial, this outcome is important. Other studies have reported the findings of ultrasonography of the paranasal sinuses in either asymptomatic patients (2) or those with known sinusitis (3), two groups that do not mimic its proposed clinical application.

2002-6 Update

A review of the literature based on the MEDLINE database for the period of 1999 through December 2005 did not identify any published peer-reviewed literature that addresses the limitations noted in the discussion here. Therefore, the policy statement is unchanged. In 2001, the American Academy of Pediatricians (AAP) published clinical practice guidelines for the management of sinusitis. (4) These guidelines note that the diagnosis of sinusitis is typically made clinically, based on the presence of upper respiratory symptoms that are either persistent or severe. Furthermore, these guidelines suggest that imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children under 6 years of age. For those under age 6, the need for radiographs as a confirmatory test of acute sinusitis is controversial. Computed tomography (CT) scanning is considered the gold standard of imaging techniques for evaluating the sinuses, but is only recommended for patients who are considering surgery. The AAP Clinical Practice Guidelines do not either discuss or recommend ultrasound of the paranasal sinuses in the diagnosis and management of sinusitis. The American Academy of Allergy, Asthma and Immunology published parameters for the diagnosis and management of sinusitis in 1998. (5) These parameters state that CT is the preferred imaging technique for preoperative evaluation of the paranasal sinus and that ultrasonography has “limited utility, but may be applicable in pregnant women and to determine the amount of retained secretions.” Finally, the American College of Radiology published Appropriateness Criteria for sinusitis in the pediatric population. (6) Levels of appropriateness, ranging from 1–9, with 1 being the least appropriate, are assigned to different sets of clinical symptoms associated with sinusitis. These criteria also suggest that CT is the most appropriate imaging modality. For all 8 symptom complexes, ultrasonography was given a 1or 2 appropriateness rating.

2006-7 Update

A review of the literature based on the PubMed® and National Institute of Health (NIH) databases, along with review of the Blue Cross Blue Shield Association (BCBSA) Technology (TEC) Assessment, for the period 2006 through April 2007, did not identify any published peer-reviewed literature that addresses the limitations noted in the above discussion. Therefore the coverage position of this policy remains investigational. Research of the literature consistently identified CT scan as the primary diagnostic tool and study of choice in evaluating the paranasal sinuses. MRI is considered a complimentary diagnostic tool as the CT scan is limited in its ability to differentiate between inflammatory and neoplastic conditions. Plain sinus filming is considered a cost effective and readily available tool to evaluate conditions of the paranasal sinuses. Plain sinus filming has almost been exclusively been replaced by CT scan. Moreover, research of the literature did not even mention ultrasound as a modality.

2009 Update

A search of peer reviewed literature through October 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2013 Update

A search of peer reviewed literature through August 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: S9024
References
  1. Haapaniemi J. Comparison of ultrasound and x-ray maxillary sinus findings in school-aged children. Ear Nose Throat J 1997; 76(2):102-6.
  2. Savolainen S, Eskelin M, Jousimies-Somer H et al. Radiological findings in the maxillary sinuses of symptomless young men. Acta Otolaryngol Supp 1997; 529:153-7.
  3. Vento SI, Ertama LO, Hytonen ML et al. A-mode ultrasound in the diagnosis of chronic polyposis sinusitis. Acta Otolaryngol 1999; 119(8):916-20.
  4. American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics 2001: 108(3):798-808.
  5. American Academy of Allergy, Asthma and Immunology. Parameters for the diagnosis and management of sinusitis. Ann Allergy Asthma Immunol 1997; 102(6 pt 2):S107-44.
  6. McAlister WH, Parker BR, Kushner DC et al. Sinusitis in the pediatric population. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215(suppl):811-8.
  7. Eggesbo, H.B. Radiological imaging of inflammatory lesions in the nasal cavity and paranasal sinuses. European Radiology (2006 April) 16(4): 872-88.
  8. Mafee, M.F., Tran, B.H., et al. Imaging of rhinosinusitis and its complications: plain film, CT, and MRI. Clinical Reviews in Allergy and Immunology (2006 June) 30(3):165-86.
  9. Da Lilly-Tariah, O.B., and J. Aniemeka. Plain radiological profile of paranasal sinuses in chronic nasal diseases in University of Port Harcourt Teaching Hospital. Nigerian Journal of Medicine; Journal of the National Association of Resident Doctors of Nigeria (2006 July-September) 15(3):305-8.
  10. Zinreich, S.J. Progress in sinonasal imaging. Annals of Otology, Rhinology and Laryngology Supplement (2006 September) 196:61-5.
  11. Ling, F.T, and S.E. Kountakis. Advances in imaging of the paranasal sinuses. Current Allergy and Asthma Reports (2006 November) 6(6):502-7.
  12. Wippold, F.J., 2nd. Head and neck imaging: the role of CT and MRI. Journal of Magnetic Resonance Imaging (2007 March) 25(3):453-65.
  13. Ultrasound for the Evaluation of Paranasal Sinuses-Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2008 October) Radiology 6.01.14.
History
August 2013  New 2013 BCBSMT medical policy.  Ultrasound in the evaluation of paranasal sinuses is considered not medically necessary. 
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Ultrasound for the Evaluation of Paranasal Sinuses