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MP 6.01.14 Ultrasound for the Evaluation of Paranasal Sinuses (Archived)

Medical Policy
Section
Radiology
 
Original Policy Date
03/31/96
Last Review Status/Date
Archived/9:2009
Issue
10:2008
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


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.


Policy

Ultrasound in the evaluation of paranasal sinuses is considered investigational.


Policy Guidelines

There is no specific CPT code for ultrasound of the paranasal sinuses. However, there is a HCPCS code that describes this procedure (S9024).

ICD-9 code 473 may be used to identify chronic sinusitis.


Benefit Application

BlueCard/National Account Issues

State or federal mandates (e.g., FEP) may dictate that all devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.


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 above discussion. 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. 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.

2007 Update

A literature search performed using MEDLINE through July 2007 did not identify any published literature that would alter the policy statement noted above.

2008 Update

A literature search performed using MEDLINE through August 2008 did not identify any published literature that would alter the policy statement noted above.

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.

 

Codes

Number

Description

CPT  76536  Echography, soft tissues of head and neck, B scan and/or real time with image documentation 
ICD-9 Diagnosis  461.0-461.9 Acute sinusitis code range
  473.0-461.9 Chronic sinusitis code range
HCPCS  S9024  Ultrasound paranasal sinuses 
Type of Service  Radiology 
Place of Service  Outpatient
 
Physician’s Office
 


Index

Nasal Sinus Ultrasound
Paranasal Sinuses, Ultrasound
Ultrasound, Paranasal Sinuses


Policy History

Date Action Reason
03/31/96 Add to Radiology section New policy
06/18/99 Replace policy Updated; policy unchanged
10/08/02 Replace policy Policy updated with literature review; no change in policy statement
02/25/04 Replace policy Policy updated with literature review; no change in policy statement
03/15/05 Replace policy Policy updated with literature review; no change in policy statement
03/7/06 Replace policy Policy reviewed with literature search; no change in policy statement
09/18/07 Replace policy Policy reviewed with literature search, no change in policy statement
10/07/08 Replace policy  Policy reviewed with literature search; no change in policy statement 
09/2009 Policy Archived  


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