Diagnosed with Chronic Sinusitis? Here's What to Do About Your Medical Aid

Chronic sinusitis is not CDL or PMB for routine management — but FESS surgery, when indicated, is PMB. The strategic question for every CRS patient is: am I building the clinical record that will support a FESS pre-authorisation if I need it? Here's how to manage both the day-to-day reality and the path to surgical funding.

The Honest Starting Point

The financial picture for chronic sinusitis is mostly day-to-day. The good news: effective medical management — intranasal corticosteroids + saline irrigation — is inexpensive (R200–R600/month) and genuinely works for many patients.

The key effort is documentation: if you ultimately need FESS, you need a documented record of failed medical management. This is the primary requirement for PMB surgical pre-authorisation.

Step 1: Build Your Medical Management Record

Start a GP/ENT-documented treatment record from the first consultation. What gets documented:

• Diagnosis date and presenting symptoms
• CT paranasal sinuses (or nasal endoscopy) — confirming CRS
• Intranasal corticosteroid: which one, dose, start date, patient's compliance, outcome assessment
• Saline irrigation: patient advised and using it
• Antibiotic courses if given for exacerbations — dates and duration
• Allergy test results if performed
• Outcome assessments at each review: improved/unchanged/worsened

After 8–12 weeks of documented, appropriate medical management without adequate response — this record supports a FESS pre-authorisation as a PMB event.

Step 2: Get an ENT Referral

If GP management has not controlled your CRS adequately, request an ENT specialist referral. An ENT specialist will:

• Perform nasal endoscopy (examination of the nasal cavity and sinus openings under direct vision)
• Review and interpret your CT paranasal sinuses
• Assess the degree of disease and whether surgical intervention is indicated
• Provide the clinical motivation letter for FESS pre-authorisation if surgery is recommended

Day-to-day cost: ENT specialist consultation R500–R1,500. Usually funded from your specialist benefit or ATB.

Step 3: Get a CT Paranasal Sinuses

The Lund-Mackay scoring system on CT guides severity classification. Pre-surgical CT is standard.

Ask your scheme: "My ENT has confirmed I need a CT paranasal sinuses prior to FESS planning. Please confirm radiology pre-authorisation."

If your scheme requests a reason: "Documented chronic rhinosinusitis requiring CT for surgical planning (FESS pre-authorisation)." This should be covered under your radiology benefit.

Cost if OOP: R2,500–R5,000.

Step 4: Request FESS Pre-Authorisation

Once your ENT recommends FESS, the pre-authorisation submission should include:

• ENT clinical motivation letter: diagnosis, duration of symptoms, CT findings (attach report), medical treatments tried (intranasal corticosteroid + saline ± antibiotics) and failure to respond, reason surgery is recommended
• ICD-10 code: J32.4 (chronic pansinusitis), J32.0 (chronic maxillary sinusitis), J32.9 (chronic sinusitis, unspecified), J33.0 (polyp of nasal cavity) — as applicable
• Procedure: FESS (sinus surgery, often combined with septoplasty and/or turbinoplasty)

Call your scheme: "I am requesting pre-authorisation for FESS for chronic rhinosinusitis that has failed adequate medical management. My ENT has prepared a clinical motivation. Can you confirm this as a PMB DTP and provide pre-auth?"

Step 5: Notify Gap Cover Before FESS

ENT surgeons performing FESS charge above scheme rate in most cases. The gap shortfall can be R10,000–R40,000 (surgeon + anaesthesiologist combined).

Call your gap insurer: "I am having FESS at [hospital] with Dr [name]. Please note my gap cover pre-notification and confirm my OPL balance."

Step 6: Plan Post-Operative Management

FESS success depends heavily on post-operative care. Your ENT will advise:

• Saline irrigation 2–3 times daily starting 24–48 hours post-operatively — essential for crust clearance, wound healing, and infection prevention
• Intranasal corticosteroid spray — restarted within 1–2 weeks post-operatively and continued long-term
• Follow-up nasal endoscopy at 2–4 weeks and 3 months — to debride crusts and assess healing; day-to-day cost

Budget for ongoing post-FESS management: this is day-to-day, approximately R2,000–R5,000/year in saline, nasal sprays, and ENT follow-up.

If You Have CRS + Nasal Polyps (CRSwNP)

Nasal polyps recur after FESS in many patients (30–80%). For patients with recurrent severe CRSwNP:

Dupilumab (Dupixent): A biologic (anti-IL-4/IL-13) approved for severe CRSwNP. Dramatically reduces polyp recurrence. Cost: R15,000–R20,000/month. Not CDL. Not routinely funded.

Exceptional-needs authorisation pathway: your ENT or allergist submits a clinical motivation to your scheme's medical director. Criteria: severe CRSwNP with documented recurrence after FESS, on maximum medical therapy. Success rate for funding varies by scheme.

If dupilumab is declined: appeal citing clinical need and failure of repeated FESS. CMS can adjudicate if the condition meets PMB disease severity criteria.

Key Calls to Make

Talk to Eldon

FESS is fundable as a PMB — but only with the right documentation. AURA verifies that your treatment history is correctly captured in the pre-auth motivation and that gap cover is notified, minimising unexpected out-of-pocket costs.

Review your plan for ENT and sinus surgery coverage →