Clinical UM Guideline |
Subject: Diagnostic Nasal Endoscopy | |
Guideline #: CG-SURG-57 | Publish Date: 10/01/2024 |
Status: Revised | Last Review Date: 08/08/2024 |
Description |
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:
Clinical Indications |
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:
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.
Coding |
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:
CPT |
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31231 | Nasal endoscopy, diagnostic; unilateral or bilateral (separate procedure) |
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ICD-10 Diagnosis |
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| All diagnoses |
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.
Discussion/General Information |
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:
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:
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.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Websites for Additional Information |
Index |
Nasoscopy
Rhinoscopy
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History |
Status | Date | Action |
Revised | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Added MN statement regarding eustachian tube pathology. Updated Description, Discussion and References sections. |
Reviewed | 08/10/2023 | MPTAC review. Updated Discussion and References section. |
Reviewed | 08/11/2022 | MPTAC review. Updated Discussion and References section. |
Reviewed | 08/12/2021 | MPTAC review. Updated Discussion and References sections. |
Reviewed | 08/13/2020 | MPTAC review. Updated Discussion and References sections. Reformatted Coding section. |
Reviewed | 08/22/2019 | MPTAC review. Updated References. |
Reviewed | 09/13/2018 | MPTAC review. Updated References. |
Reviewed | 11/02/2017 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion and References sections. |
Revised | 11/03/2016 | MPTAC review. Clinical Indications revised to include medically necessary examples for facial pain suggestive of rhinogenic origin, recurrent or single severe posterior nasal epistaxis and endoscopically guided cultures. Updated Description, Discussion and References sections. |
New | 08/04/2016 | MPTAC review. Initial document development. |
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