|
Medical Policy: 06.01.03
Original Effective Date: October 1999
Reviewed: November 2007
Revised: July 2004
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
Description:
Computer-augmented image guidance for endoscopic sinus surgery is used to provide field orientation to the viewing plane of the endoscope. MRI or CT scans are obtained prior to the surgery and are translated into digital maps of the patient’s anatomy that are used during the operation to give the surgeon a better understanding of the structures not visible through the endoscope. The digital images become an integral part of the surgical procedure in addition to assisting surgical planning. A headset registration is used during the diagnostic scan, and is worn by the patient during the surgery to provide the surgeon with an accurate view of anatomical structures that would not otherwise be visible.
Policy:
Computer-augmented endoscopic sinus surgery may be considered medically necessary when any one of the following criteria are met:
- When the anatomy is altered or obscured by prior surgery, trauma, neoplasms or extensive sino-nasal polyposis
- CSF rhinorrhea or conditions involving skull base defects
- Disease abutting the skull base, orbit, optic nerve or carotid artery
- Surgeries on the frontal sinuses will be individually reviewed by the medical director
Prior approval is recommended. Submit a prior approval now.
Computer-augmented endoscopic sinus surgery is not a covered benefit for any condition not listed above.
 Top
Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code 61795 should be used for the sterotactic computer-assisted volumetric procedure. It should be listed in addition to the primary procedure code.
Top
Selected References:
- Klimek, L., Mosges, R., Schlondorff, G., Mann, W. Development of computer-aided surgery for otorhinolaryngology. Computer Aided Surgery 1998;3:194-201.
- Fried, M.P., Kleefield, J., Gopal, H., Reardon, E., Ho, B.T., Kuhn, F.A. Image-Guided Endoscopic Surgery: Results of accuracy and performance in a multicenter clinical study using an electromagnetic tracking system. Laryngoscope 1997; May 107:594-601.
- Anon, J.B. Computer-aided Endoscopic Sinus Surgery. Laryngoscope 1998; 108:949-961.
- Metson, R., Gliklich, R.E., Cosenza, M. A comparison of image guidance systems for sinus surgery. Laryngoscope 1998; 108:1164-1170.
- Hilbert, M., Muller, W. Virtual reality in endonasal surgery. Studies in Health Technology and Information 1997;39:237-245.
- Casiano, R.R. Intraoperative Image-Guidance Technology. Archives of Otolaryngology -- Head and Neck Surgery, vol 125, Nov. 1999: 1275-1278.
- Knott P, Batra P, Citardi M. Computer aided surgery: concepts and applications. Otolaryngol Clin North Am 2006 Jun;39(3): 503-22, ix.
Top
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Prior approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
|
 |
