Clinical UM Guideline

This document addresses the diagnostic use of nasal endoscopy in the office or outpatient setting. The nasal endoscope is a thin, rigid or flexible tube with an attached light source, which is passed through the nostril to evaluate the deeper internal nasal anatomy, central airway and lateral or posterior aspects of the nasal cavity and sinuses. This procedure is used when an evaluation using a nasal speculum is not adequate.

Notes:

• Please see the following documents for related information:
  • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
  • CG-SURG-56 Diagnostic Fiberoptic Flexible Laryngoscopy
  • CG-SURG-117 Balloon Dilation of the Eustachian Tubes
     
• This document does not address diagnostic nasopharyngoscopy

Medically Necessary:

The use of diagnostic nasal endoscopy is considered medically necessary for the initial evaluation and visualization of the nasal anatomy when the following criteria are met:

1. There are symptoms suggestive of nasal, eustachian tube or sinus pathology and
2. The physical examination (including a nasal speculum evaluation) does not provide sufficient clinical information to establish a diagnosis.
   This includes, but is not limited to:
   1. Evaluate chronic sinonasal symptoms when there is a suspicion of:
      1. Nasal obstruction not due to septal deviation that is refractory to medical therapy; or
      2. Chronic sinusitis
   2. Monitor for recurrent nasal polyps
   3. Initial diagnosis or interval surveillance of sinonasal neoplasms
   4. Evaluate clear rhinorrhea if cerebrospinal fluid leak is suspected
   5. Assessment of facial pain suggestive of rhinogenic origin
   6. Evaluation of recurrent or single severe posterior nasal epistaxis
   7. Endoscopically guided cultures for recurrent sinusitis which has failed empiric antibiotic therapy or if empiric antibiotic therapy is limited by drug allergies
   8. Evaluation of the eustachian tube:
      1. Part of the diagnostic evaluation; or
      2. Assess individuals who are candidates for balloon dilation of the eustachian tube.

A repeat diagnostic nasal endoscopy is considered medically necessary when the symptoms do not improve or worsen following treatment (medical/surgical).

Not Medically Necessary:

Nasal endoscopy is considered not medically necessary when the criteria above have not been met, and for all other indications, including as a screening tool in the evaluation of an asymptomatic individual.

The following codes for treatments and procedures applicable to this guideline 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.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Nasal endoscopy is an established diagnostic tool used to evaluate the nasal passages and structures which are inaccessible by nasal speculum. The American Academy of Allergy, Asthma & Immunology work group report on nasal and sinus endoscopy in resistant rhinosinusitis (2006) notes:

Endoscopy is a useful technique that affords the allergist the ability to assess and localize sinus pathology with far greater precision than a routine nasal exam. Use of endoscopy can also improve diagnostic accuracy and thereby reduce costly and unnecessary medication usage (e.g., antibiotics).

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline strongly recommends the use of nasal endoscopy to confirm a diagnosis of chronic rhinosinusitis.

In the 2010 AAO-HNS guideline on the diagnosis and management of nasal valve compromise (NVC), there was consensus among the panel that nasal endoscopy is useful in ruling out causes of symptomatic nasal obstruction other than NVC. While nasal endoscopy may be useful in diagnosing NVC, there was no consensus on whether endoscopy is routinely indicated.

The National Comprehensive Cancer Network (NCCN^®) Clinical Practice Guideline for Head and Neck Cancers (V.4.2024) includes a 2A recommendation for nasal endoscopy, when clinically indicated, for the workup of ethmoid and maxillary sinus tumors. The NCCN does not include recommendations for repeat nasal endoscopies following the initial diagnostic work-up.

The AAO-HNS 2015 clinical indications note that for diagnostic nasal endoscopy to be appropriate, at least one of the following conditions should be present:

1. Anterior rhinoscopy insufficient to account for symptoms.
2. Abnormal anterior rhinoscopy requiring more thorough nasal evaluation, including, but not limited to suspected chronic rhinosinusitis, sinonasal polyposis, neoplasm, and/or foreign body.

The AAO-HNS clinical practice guideline on nosebleed (2020) includes recommendations regarding when nasal endoscopy in the evaluation of nosebleeds. Approximately 6% of individuals who experience a nosebleed will seek out medical treatment. The guideline is targeted to those individuals with “bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient’s quality of life.” The guideline addresses nasal endoscopy in the following recommendations:

Statement 7a. Examination using Nasal Endoscopy: The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. Recommendation based on observational studies and a preponderance of benefit over harm.

Statement 7b. Examination of Nasal Cavity and Nasopharynx using Nasal Endoscopy: The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis. Option based on observational studies with a balance of benefits and harms.

In a position statement on diagnostic nasal endoscopy (2019), the American Rhinologic Society (ARS) lists common indications for the use of nasal endoscopy as a diagnostic tool which includes:

• Evaluate for chronic sinonasal symptoms;
• Assessment of interval response to medical or surgical therapy;
• Monitoring for recurrence sinusitis and/or nasal polyps;
• Evaluation and management epistaxis;
• Performance of endoscopically guided cultures;
• Assessment of facial pain suggestive of rhinogenic origin;
• Evaluation clear rhinorrhea suggestive of cerebrospinal fluid leak;
• Performance of initial diagnosis and interval surveillance for sinonasal neoplasms; or
• Evaluation of smell disorders

The ARS notes “Diagnostic nasal endoscopy is a procedure performed to better characterize the anatomy of the nasal cavity and/or paranasal sinuses and to identify sinonasal pathology not afforded by anterior rhinoscopy.”

The AAO-HNS clinical consensus statement regarding balloon dilation of the eustachian tube (BDET) provides several recommendations for performing nasal endoscopy during the diagnostic phase and when evaluating individuals with eustachian tube dysfunction (ETD) who are candidates for BDET (Tucci, 2019). The recommendations relevant to nasal endoscopy that reached clinical consensus are noted below:

2. Nasal endoscopy is an essential part of the diagnostic evaluation prior to BDET.
4. Nasal endoscopy in patients who are candidates for BDET is necessary for assessing the ET lumen and assessing the feasibility of transnasal access to the nasopharynx.
11. Nasal endoscopy is necessary to rule out extrinsic causes of ETD.

In 2019, Chainansamit and colleagues evaluated the sensitivity and specificity of traditional nasal examination tools when compared to the sensitivity and specificity of the rigid endoscope in 53 individuals with nasal symptoms. Participants were examined using six methods: anterior rhinoscopy using a nasal speculum and otoscope (with and without topical anesthesia and decongestants for each tool), posterior rhinoscopy using a mirror, and rigid nasal endoscopy. The authors rated the specificity of the nasal speculum and otoscope, with and without topical anesthesia and decongestants, as excellent while the sensitivity was rated as average. The posterior rhinoscopy with a mirror had the lowest sensitivity and authors did not recommend using this tool to rule out pathologies of the posterior nasal cavity. The nasal endoscope resulted in more complications compared to the other tools. Nasal endoscopy use resulted in 40 (75.5%) individuals experiencing pain, 21 (39.6%) individuals experiencing discomfort and 2 (3.8%) individuals experiencing minor bleeding. Only one individual reported pain from the nasal speculum, otoscope, and posterior rhinoscopy mirror.

Peer Reviewed Publications:

1. Bhattacharyya N, Lee LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg. 2010; 143(1):147-151.
2. Chainansamit S, Chit-Uea-Ophat C, Reechaipichitkul W, Piromchai P. The diagnostic value of traditional nasal examination tools in an endoscopic era. Ear Nose Throat J. 2019:145561319875711.
3. Hopkins C. Chronic rhinosinusitis with nasal polyps. N Engl J Med. 2019; 381(1):55-63.
4. Jiang ZY, Kou YF, Batra PS. Endoscopic culture-directed antibiotic therapy: Impact on patient symptoms in chronic rhinosinusitis. Am J Otolaryngol. 2015; 36(5):642-646.
5. Krouse J, Lund V, Fokkens W, Meltzer EO. Diagnostic strategies in nasal congestion. Int J Gen Med. 2010; 3:59-67.
6. Lee K, Adamovich-Zeitlin R, Svrakic M. Making recommendations for an evaluation and treatment algorithm for patients with ear fullness and no objective abnormalities. Otol Neurotol. 2024; 45(4):447-453.
7. Marseglia GL, Pagella F, Klersy C, et al. The 10-day mark is a good way to diagnose not only acute rhinosinusitis but also adenoiditis, as confirmed by endoscopy. Int J Pediatr Otorhinolaryngol. 2007; 71(4):581-583.
8. Ryan WR, Ramachandra T, Hwang PH. Correlations between symptoms, nasal endoscopy, and in-office computed tomography in post-surgical chronic rhinosinusitis patients. Laryngoscope. 2011; 121(3):674-678.
9. Wuister AM, Goto NA, Oostveen EJ, et al. Nasal endoscopy is recommended for diagnosing adults with chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014; 150(3):359-364.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). Clinical Indicators: Diagnostic Nasal Endoscopy. Updated January 2015.
2. American Rhinologic Society (ARS). Position Statement – Diagnostic Nasal Endoscopy (31231). Revised September 13, 2019. Available at: https://www.american-rhinologic.org/index.php?option=com_content&view=article&id=34:nasal-endoscopy---cpt-31231&catid=26:position-statements&Itemid=197. Accessed on June 14, 2024.
3. Han JK, Stringer SP, Rosenfeld RM, et al. Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction. Otolaryngol Head Neck Surg. 2015; 153(5):708-720.
4. NCCN Clinical Practice Guidelines in Oncology^® (NCCN). ^© 2024 National Comprehensive Cancer Network, Inc. Head and Neck Cancers (V.4.2024). Revised May 1, 2024. For additional information visit the NCCN website: http://www.nccn.org. Accessed on July 30, 2024.
5. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010; 143(1):48-59.
6. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2 Suppl):S1-S39.
7. Slavin RG, Spector SL, Bernstein IL et al.; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 2005; 116(6 Suppl):S13-S47. Archived.
8. Stankiewicz JA, Chow JM. Nasal endoscopy and the definition and diagnosis of chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2002; 126(6):623-627.
9. Tucci DL, McCoul ED, Rosenfeld RM, et al. Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube. Otolaryngol Head Neck Surg. 2019; 161(1):6-17.
10. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngol Head Neck Surg. 2020; 162(1):8-25.
11. Wallace DV, Dykewicz MS, Bernstein DI, et al; Joint Task Force on Practice; American Academy of Allergy; Asthma & Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008; 122(2 Suppl):S1-S84.

1. U.S. National Library of Medicine. MedlinePlus. Nasal Endoscopy. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/007627.htm. Accessed on June 14, 2024.
2. U.S. National Library of Medicine. MedlinePlus. Sinusitis. Reviewed on May 30, 2022. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/000647.htm. Accessed on June 14, 2024.

Nasoscopy
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