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Date Printed: October 20, 2017: 08:42 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-76500-06

Original Effective Date: 11/15/01

Reviewed: 07/27/17

Revised: 08/15/17

Subject: Ultrasound for the Evaluation of Paranasal Sinuses

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

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 nonionizing and non-invasive when compared to the conventional diagnostic alternatives of radiography or sinuscopy for sinus evaluation.

POSITION STATEMENT:

Ultrasound in the evaluation of paranasal sinuses does not meet the definition of medical necessity. 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. CT scans are the most common choice and are considered the gold standard of practice.

BILLING/CODING INFORMATION:

HCPCS Coding:

S9024

Paranasal sinus ultrasound

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report ultrasound for the evaluation of paranasal sinuses:

Nasal Sinus Ultrasound
Paranasal Sinuses, Ultrasound
Ultrasound, Paranasal Sinuses

REFERENCES:

  1. American Academy of Pediatricians (AAP) Clinical practice guideline: management of sinusitis. Pediatrics 2001; 108(3): 798-808.
  2. American College of Radiology Appropriateness Criteria Sinusitis – Child. Date of origin 1995 (last review date 2012).
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual, Ultrasound for the Evaluation of Paranasal Sinuses 6.01.14, 10/08; archived 09/09.
  4. Chow AW, Benninger MS, Brook I et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Disease 2012; 54(8): e72-e112.
  5. Engels, E. A., Terrin, N., Barza, M. & Lau, J. Meta-analysis of diagnostic tests for acute sinusitis. Journal of Clinical Epidemiology 2000; 53(8), 852-62.
  6. Ioannidis JPA, Lau J. American Academy of Pediatrics Technical Report: Evidence for the Diagnosis and Treatment of Acute Uncomplicated Sinusitis in Children: A Systematic Overview. Pediatrics 2001; 108(3): p. e57.
  7. Jecker P, Diagnostic Use of Ultrasound for Examination of the Nose and the Paranasal Sinuses, Ultraschall Med. 2005 Dec; 26(6): 501-6.
  8. Journal Council of Allergy, Asthma and Immunology-Practice parameters for the Diagnosis and Management of Sinusitis-D. Imaging Studies in the Evaluation of Sinusitis Summary Statements, 2005.
  9. Masood A, Moumoulidis I, Panesar J. Acute rhinosinusitis in adults: an update on current management. Postgraduate Medical Journal 2007; 83 (980): 402-408.
  10. National Guideline Clearinghouse (NGC). Guideline summary: Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Jul 01.
  11. Osguthorpe JD. Acute Rhinosinusitis: Diagnosis and Management. American Family Physician 2001; 63(1): 69-76.
  12. Pruna, X., Inaraja, L., Gallardo, E., Serra, J., Casamitjana, F., & Serrano, A. Value of sonography in the assessment of space-occupying lesions of the anterior nasal fossa. Journal of Clinical Ultrasound, 2000 28(1), 14-19.
  13. Reider, J.M., & Nashelsky, J. Do imaging studies aid diagnosis of acute sinusitis? Journal of Family Practice 2003, 52(7).
  14. Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline: Adult sinutitis. American Academy of Otolaryngology-Head and Neck Surgery 2007; 137: S1-S31.
  15. Scheid DC, Hamm RM. Acute Bacterial Rhinosinusitis in Adults: Part I and Part II. Evaluation. American Family Physician 2004; 70(9): 1685-1704.
  16. Vento, S. I., Ertama, L. O., Hytonen, M. L., & Malmberg, C. H. A-mode ultrasound in the diagnosis of chronic polypous sinusitis. Acta Otolaryngology 1999, 119(8), 916-20.
  17. Wald ER, Applegate KE, Bordley C et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013; 132(1): e262-e280.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/27/17.

GUIDELINE UPDATE INFORMATION:

04/17/00

New Medical Coverage Guideline.

11/15/01

Reformatted & reviewed – investigational.

11/15/03

Reviewed & updated – investigational.

12/15/04

Annual review & update – maintain investigational.

01/01/06

Scheduled review. Changed investigational status to not medically necessary. Updated references.

09/15/06

Scheduled review. Updated references.

08/15/07

Annual review; coverage statement maintained, guideline reformatted, references updated.

09/15/08

Scheduled review. No change in position statement. Updated references.

09/15/10

Annual review. Updated and reformatted description. Deleted related Internet link. Update references.

05/11/14

Revision: Program Exceptions section updated.

08/15/17

Review; no change in position statement. Updated references.

Date Printed: October 20, 2017: 08:42 AM