Clinical UM Guideline


Subject: Functional Endoscopic Sinus Surgery (FESS)
Guideline #:  CG-SURG-24 Publish Date:    08/02/2018
Status: Revised Last Review Date:    07/26/2018


This document addresses the use of functional endoscopic sinus surgery (FESS), an endoscopic surgical procedure used to treat various conditions of the nasal sinuses, including but not limited to chronic sinusitis.

Note: Please see the following document for related information:

Clinical Indications

Medically Necessary:

Functional endoscopic sinus surgery (FESS) is considered medically necessary for the treatment of sinusitis, polyposis, or sinus tumor when any one of the following circumstances is present:

  1. Suspected tumor seen on imaging, physical examination, or endoscopy; or
  2. Suppurative (pus forming) complications, including but are not limited to:
    1. Subperiosteal abscess; or
    2. Brain abscess; or
  3. Chronic polyposis with symptoms unresponsive to medical therapy, including, but not limited to the following:
    1. Oral steroids; and
    2. Oral antibiotics when indicated; and
    3. Topical nasal steroid sprays; or
  4. Allergic fungal sinusitis, as indicated by all of the following:
    1. Nasal polyposis; and
    2. Positive CT findings; and
    3. Eosinophilic mucus; or
  5. Mucocele causing chronic sinusitis; or
  6. Recurrent sinusitis that triggers or aggravates pulmonary disease, such as asthma or cystic fibrosis; or
  7. Uncomplicated sinusitis (for example, sinusitis confined to the paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures) and all (1, 2, and 3) of the following:
    1. Either of the following:
      1. Four or more documented episodes of acute rhinosinusitis (for example, less than 4 weeks duration) in one year; or
      2. Chronic sinusitis (for example, greater than 12 weeks duration) that interferes with lifestyle; and
    2. Maximal medical therapy has been attempted, as indicated by all of the following:
      1. Antibiotic therapy; and
      2. Trial of inhaled steroids; and
      3. Nasal lavage; and
      4. Allergy testing (if symptoms are consistent with allergic rhinitis and have not responded to appropriate environmental controls and pharmacotherapy [antihistamines, intranasal corticosteroids, leukotriene antagonists, etc.]); and
    3. Abnormal findings from diagnostic work-up, as indicated by any one of the following:
      1. CT findings suggestive of obstruction or infection for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitis, or diffuse opacification; or
      2. Nasal endoscopy findings suggestive of significant disease; or
      3. Physical exam findings suggestive of chronic/recurrent disease (for example, mucopurulence, erythema, edema, inflammation); or
  8. Fungal mycetoma; or
  9. Persistent sinus symptoms following any prior sinus surgery; or
  10. Cerebrospinal fluid rhinorrhea; or
  11. Encephalocele; or
  12. Posterior epistaxis (relative indication); or
  13. Persistent facial pain after other causes ruled out (relative indication); or
  14. Cavernous sinus thrombosis caused by chronic sinusitis.

Nasal or sinus cavity debridement following FESS is considered medically necessary for any of the following circumstances:

  1. Twice during the first 30 days postoperatively; or
  2. Postoperative loss of vision or double vision; or
  3. Evidence of cerebrospinal fluid leak such as rhinorrhea; or
  4. When prompted by physical obstruction of the sinus opening related to:
    1. Nasal polyps unresponsive to oral or nasal steroids; or
    2. Documented presence of papilloma, carcinoma or other neoplasm; or
    3. Allergic fungal sinusitis.

Not Medically Necessary: 

Functional endoscopic sinus surgery is considered not medically necessary for the treatment of sinusitis, polyposis, sinus tumor, or any other condition when the criteria above are not met.

Nasal or sinus cavity debridement following FESS is considered not medically necessary when criteria above are not met, including additional post-surgical debridement beyond 30 days post-procedure.


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




Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [when specified as debridement following sinus surgery]


Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed


Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)


Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)


Nasal/sinus endoscopy, surgical, with maxillary antrostomy


Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy


Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus


Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus


Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed


Nasal/sinus endoscopy, surgical, with sphenoidotomy


Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus






Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity(s), unilateral or bilateral



ICD-10 Procedure



Destruction of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal ethmoid or sphenoid; includes codes 095P4ZZ, 095Q4ZZ, 095R4ZZ, 095S4ZZ, 095T4ZZ, 095U4ZZ, 095V4ZZ, 095W4ZZ, 095X4ZZ]


Drainage of sinus, percutaneous endoscopic approach [with or without device, accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 099P40Z, 099P4ZZ, 099Q40Z, 099Q4ZZ, 099R40Z, 099R4ZZ, 099S40Z, 099S4ZZ, 099T40Z, 099T4ZZ, 099U40Z, 099U4ZZ, 099V40Z, 099V4ZZ, 099W40Z, 099W4ZZ, 099X40Z, 099X4ZZ]


Excision of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09BP4ZZ, 09BQ4ZZ, 09BR4ZZ, 09BS4ZZ, 09BT4ZZ, 09BU4ZZ, 09BV4ZZ, 09BW4ZZ, 09BX4ZZ]


Extirpation of matter from sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09CP4ZZ, 09CQ4ZZ, 09CR4ZZ, 09CS4ZZ, 09CT4ZZ, 09CU4ZZ, 09CV4ZZ, 09CW4ZZ, 09CX4ZZ]


Extraction of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09DP4ZZ, 09DQ4ZZ, 09DR4ZZ, 09DS4ZZ, 09DT4ZZ, 09DU4ZZ, 09DV4ZZ, 09DW4ZZ, 09DX4ZZ]


Inspection of sinus, percutaneous endoscopic approach


Release sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09NP4ZZ, 09NQ4ZZ, 09NR4ZZ, 09NS4ZZ, 09NT4ZZ, 09NU4ZZ, 09NV4ZZ, 09NW4ZZ, 09NX4ZZ]


Repair sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09QP4ZZ, 09QQ4ZZ, 09QR4ZZ, 09QS4ZZ, 09QT4ZZ, 09QU4ZZ, 09QV4ZZ, 09QW4ZZ, 09QX4ZZ]


Resection of sinus, percutaneous endoscopic approach [accessory, maxillary, frontal, ethmoid or sphenoid; includes codes 09TP4ZZ, 09TQ4ZZ, 09TR4ZZ, 09TS4ZZ, 09TT4ZZ, 09TU4ZZ, 09TV4ZZ, 09TW4ZZ, 09TX4ZZ]



ICD-10 Diagnosis





Benign neoplasm of nasal cavities, middle ear, and accessory sinuses


Neoplasm of uncertain behavior of other respiratory organs (accessory sinuses)


Neoplasm of uncertain behavior of respiratory organ, unspecified


Intracranial and intraspinal phlebitis and thrombophlebitis

J01.00- J01.91

Acute sinusitis


Chronic sinusitis


Nasal polyps




Encounter for other specified surgical aftercare

Discussion/General Information

Functional Endoscopic Sinus Surgery (FESS)

FESS is the most commonly used surgical technique to treat medically unresponsive chronic sinusitis and other serious conditions of the nasal sinuses that result in impaired sinus drainage. FESS utilizes small fiberoptic tools to access the nasal sinuses through the nasal opening to remove diseased tissue and bone, resulting in opened sinus passageways, improved mucus drainage, and promotion of healthy tissue growth.

Prior to the creation and adoption of FESS, the standard treatment method involved the creation of a surgical opening in the upper jaw above the front teeth. The use of FESS allows for a much less invasive and traumatic procedure, resulting in shorter surgery and healing times, less postoperative discomfort, and fewer surgical complications.

Despite having been widely adopted as the standard of care, only a few controlled trials evaluating the use of FESS for various conditions are currently available in the medical literature. One randomized controlled trial (RCT) by Blomqvist (2001) compared medical treatment for nasal polyps with surgery followed by medical treatment in 32 subjects with a follow-up of 1 year. The authors reported that surgery reduced the polyp score and improved nasal obstruction symptoms, but did not help with hyposmia (reduced sense of smell). Another study by Penttila (1997) reported the results of a randomized study comparing FESS vs. the Caldwell-Luc (C-L) open procedure for the treatment of chronic maxillary sinusitis. Follow-up ranged from 5 to 9 years with 128 individuals responding. The authors report that the outcomes for the FESS group were approximately equivalent to that in the C-L group.

A prospective, randomized controlled trial of medical vs. surgical treatment of polypoid and nonpolypoid chronic rhinosinusitis (CRS) is described by Ragab and colleagues (2004). In this study, 90 people with CRS were randomized to either medical or surgical therapy with FESS. The study found that both the medical and surgical treatments for CRS significantly improved almost all subjective and objective parameters of CRS with no significant difference being found between the two groups. The authors conclude that CRS should initially be treated with maximal medical therapy (e.g., antibiotics and topical steroids), with surgical treatment being reserved for cases refractory to medical therapy.

Finally, a Cochrane review of FESS for the indication of chronic rhinosinusitis from May 2006 concluded:

The evidence available does not demonstrate that FESS, as practiced in the included trials, is superior to medical treatment with or without sinus irrigation in patients with chronic rhinosinusitis. There were no major complications in any of the included trials and FESS appears to be a safe procedure. More randomised controlled trials comparing FESS with medical and other treatments, with long-term follow up, are required.

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a consensus statement regarding pediatric chronic rhinosinusitis in 2014 (Brietzke, 2014). The following statements were made in this document:

23. Endoscopic sinus surgery (ESS) is an effective procedure for treating pediatric chronic rhinosinusitis (PCRS) that is best performed after medical therapy, adenoidectomy, or both have failed.
25. Image-guided ESS is useful for revision ESS cases and/or for patients with extensive nasal polyposis that can distort anatomical landmarks.

Although the literature-based evidence addressing FESS is limited, the clinical experience over the past decade has demonstrated the safety and efficacy of this procedure compared to more invasive techniques.

The criteria for maximal medical therapy, including a trial of antibiotic therapy is based partially on the AAO-HNS recommendations mentioned above, and on consensus recommendations based on the relative risks and benefits of medical vs. surgical treatment.

Postoperative Debridement

There have been several studies addressing the use of nasal or sinus postoperative debridement after FESS surgery, although the results have been mixed with regard to whether or not there is benefit of this procedure. A small study found no significant benefit from debridement (Nilssen, 2002), and another found only minor symptomatic benefit when debridement was performed during the first postoperative week (Kemppainen, 2008). Another study found that debridement significantly reduces crusting and postoperative adhesions as compared with saline irrigation, but was associated with significantly more postoperative pain (Bugten, 2006). The authors reported that at 12 weeks after surgery, there were no significant differences between individuals receiving or not receiving debridement in terms of polyps, edema, crusting, and discharge. A very small randomized trial suggested that 1 week intervals were optimal for performing debridement, which the authors indicate is currently most often performed in a large number of clinical settings (Lee, 2008). Fishman and colleagues conducted a prospective, randomized controlled, single-blinded, within-subject trial involving 24 subjects who underwent FESS and were followed for 3 months posoperatively (2011). Each subject had frequent endoscopic cleaning on one side versus minimal intervention on the other in the early postoperative period. The authors reported that there was no overall statistically significant difference between the two groups (p=0.37). A post-hoc subgroup analysis revealed a significant effect of regular suction clearance on adhesions at 3 months (p=0.048), but not on edema, polyps, granulation, discharge or crusting. An RCT reported by Alsaffar (2013) involved 58 subjects randomized to receive either two postoperative debridements at 2 and 4 weeks (n=28) or no debridement (n=30). The authors reported that at 4 weeks there was no difference between the groups in regard to Lund-Kennedy Endoscopic Score (p=0.59) or SNOT-21 scores (p=0.47). Similar results were reported at 6 months (Lund-Kennedy Endoscopic Score, p=0.46; SNOT-21, p=0.71). Although both groups reported low overall levels of pain in the early postoperative time period based on visual analog scale measurements, the debridement group had significantly higher overall pain score vs. controls (p=0.019). Finally, the authors investigated the difference in inconvenience between the two groups using the PostOperative Inconvenience Scale (POIS). A significant difference between groups was reported, with the debridement group significantly more inconvenienced than the control group (p=0.002).

In 2016, Varsak and colleagues published the results of an RCT involving 62 subjects with CRS who underwent FESS. Subjects were assigned to undergo post-operative debridement once at post-op week 1 or at post-op weeks 1, 2 and 4. Assessments were taken with a visual analog scale for nine main symptoms concerning patient discomfort within the first 4 weeks, the Lund-Kennedy endoscopic score at weeks 4 and 24, and with the SNOT-20 at week 24. The results indicated that in the single debridement group, visual analog scores at post-op week 4 showed significantly less discomfort at visits (p=0.004) and less negative effects on their work (p=0.013). No statistically significant differences were reported between the two groups in the week 4 and 24 Lund-Kennedy endoscopic score and in the week 24 SNOT-20 scores (p>0.05). The authors concluded that frequent debridement causes more discomfort at the required visits, more facial pain and more negative effects on patients' work, and that it was not superior to single seventh-day debridement.

Shi (2015) described the results of an RCT involving 67 subjects with CRS randomized to receive either three post-op debridements at 1, 4, and 8 weeks (low frequency) or weekly debridements for 8 weeks post-op (high frequency). At 4 weeks, the complaints of facial pain on a 10-point visual analog scale were significantly less severe in the low frequency group vs. the high frequency group (2.74 vs. 5.92, p<0.01). There were significantly fewer severe nasal blockages noted in the high frequency group (3.45 vs. 4.83, p<0.05). Based on endoscopic findings and Lund-Kennedy Endoscopic Score, at 4 weeks there were no significant differences regarding the presence of polyps, edema or discharge between the groups. However, a significantly lower incidence of severe crusts were noted in the high frequency group (1.12 vs. 1.90, p=0.003), but less scaring in the low frequency group (1.11 vs. 0.83 ± 0.78, p<0.01). At 8 weeks, no significant differences were noted between groups on all domains of the visual analog scale and Lund-Kennedy Endoscopic Score, except less scaring in the high frequency group (0.47 vs. 0.67, p<0.01). They concluded that the benefit of frequent debridement during the early postop period was not in positive correlation with patients recovering from ESS, and that excessive debridement may induce more surgical trauma and cause more facial pain to patients.

As noted above, the AAO-HNS published a consensus statement regarding pediatric chronic rhinosinusitis (Brietzke, 2014). The following statement addressing debridement was made in this document:

27. Postoperative debridement after ESS for PCRS is not essential for treatment success.

Postoperative debridement may need to occur for longer periods in some individuals with conditions that may lead to the development of complications. Such individuals include those with severe resistant nasal polyposis, neoplasm, or allergic fungal sinusitis. However, even in these individuals, debridement should be prompted by symptoms which arise as a consequence of the more extensive surgery or underlying disease. There is no evidence that debridement absent symptoms, even with these risk factors for complications after FESS, is associated with improved outcomes.


Peer Reviewed Publications:

  1. Alsaffar H, Sowerby L, Rotenberg BW. Postoperative nasal debridement after endoscopic sinus surgery: a randomized controlled trial. Ann Otol Rhinol Laryngol. 2013; 122(10):642-647.
  2. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003; 129(3 Suppl):S1-32.
  3. Blomqvist EH, Lundblad L, Anggard A, et al. A randomized controlled study evaluating medical treatment versus surgical treatment in addition to medical treatment of nasal polyposis. J Allergy Clin Immunol. 2001; 107(2):224-228.
  4. Bugten V, Norgard S, Steinsvag S. The effects of debridement after endoscopic sinus surgery. Laryngoscope. 2006; 116(11):2037-2043.                       
  5. Busaba NY, Kieff D. Endoscopic sinus surgery for inflammatory maxillary sinus disease. Laryngoscope. 2002; 112(8 Pt 1):1378-1383.
  6. Ehnhage A, Olsson P, Kölbeck KG, et al. Functional endoscopic sinus surgery improved asthma symptoms as well as PEFR and olfaction in patients with nasal polyposis. Allergy. 2009; 64(5):762-769.
  7. Fishman JM, Sood S, Chaudhari M, et al. Prospective, randomised controlled trial comparing intense endoscopic cleaning versus minimal intervention in the early post-operative period following functional endoscopic sinus surgery. J Laryngol Otol. 2011; 125(6):585-589.
  8. Hamilos DL. Chronic sinusitis. J Allergy Clin Immunol. 2000; 106(2):213-227.
  9. Kemppainen T, Seppä J, Tuomilehto H, et al. Repeated early debridement does not provide significant symptomatic benefit after ESS. Rhinology. 2008; 46(3):238-242.
  10. Kuhn FA, Javer AR. Allergic fungal rhinosinusitis: perioperative management, prevention of recurrence, and role of steroids and antifungal agents. Otolaryngol Clin North Am. 2000; 33(2):419-433.
  11. Lee JY, Byun JY. Relationship between the frequency of postoperative debridement and patient discomfort, healing period, surgical outcomes, and compliance after endoscopic sinus surgery. Laryngoscope. 2008; 118(10):1868-1872.
  12. Lieser JD, Derkay CS. Pediatric sinusitis: when do we operate? Curr Opin Otolaryngol Head Neck Surg. 2005. 13(1):60-66.
  13. Luong A, Marple BF. Sinus surgery: indications and techniques. Clin Rev Allergy Immunol. 2006; 30(3):217-222.
  14. Manning S. Surgical intervention for sinusitis in children. Curr Allergy Asthma Rep. 2001; 1(3):289-296.
  15. Nilssen E, Wardrop P, El-Hakim H, et al. A randomized control trial of post-operative care following endoscopic sinus surgery: debridement versus no debridement. J Laryngol Otol. 2002; 116(2):108-111.
  16. Orlandi RR, Kennedy DW. Surgical management of rhinosinusitis. Am J Med Sci. 1998; 316(1):29-38.
  17. Penttila MA, Rautiainen ME, Pukander JS, Karma PH. Endoscopic versus Caldwell-Luc approach in chronic maxillary sinusitis: comparison of symptoms at one-year follow-up. Rhinology. 1994; 32(4):161-165.
  18. Penttila MA, Rautiainen ME, Pukander JS, Kataja M. Functional vs. radical maxillary surgery. Failures after functional endoscopic sinus surgery. Acta Otolaryngol Suppl. 1997; 529:173-176.
  19. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope. 2004; 114(5):923-930.
  20. Rahman T, Alam MM, Ahmed S, et al. Outcome of endoscopic sinus surgery in the treatment of chronic rhinosinusitis. Mymensingh Med J. 2016; 25(2):261-270.
  21. Seiden AM, Stankiewicz JA. Frontal sinus surgery: the state of the art. Am J Otolaryngol. 1998; 19(3):183-193.
  22. Shi L, Feng Y, Cui W, et al. Effect evaluation of repeated debridement after endoscopic sinus surgery. Int J Clin Exp Med. 2015; 8(1):928-933.
  23. Smith TL, Kern R, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1-year follow-up. Int Forum Allergy Rhinol, 2013; 3(1):4-9.
  24. Varsak YK, Yuca K, Eryilmaz MA, Arbag H. Single seventh day debridement compared to frequent debridement after endoscopic sinus surgery: a randomized controlled trial. Eur Arch Otorhinolaryngol. 2016; 273(3):689-695.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Brietzke SE, Shin JJ, Choi S, et al. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014; 151(4):542-553.
  2. Khalil HS, Nunez DA. Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev. 2006;(3):CD004458.
  3. Peters AT, Spector S, Hsu J, et al.; Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014; 113(4):347-85.
  4. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2 Suppl):S1-S39.
Websites for Additional Information
  1. American Academy of Family Physicians. Functional Endoscopic Surgery. Available at: Accessed on May 22, 2018.
  2. National Library of Medicine. Medical Encyclopedia. Sinusitis. Available at: Accessed on May 22, 2018.

Functional Endoscopic Sinus Surgery
Nasal Polyposis







Medical Policy & Technology Assessment Committee (MPTAC) review. Removed MN criteria text related to time limit for antibiotic therapy for uncomplicated sinusitis. Added Websites section. Updated Rationale and References sections.



The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT changes; added 31253, 31257, 31259 and descriptor changes for 31254, 31255, 31276.



MPTAC review. Clarified MN statement criteria regarding medical therapy for polyposis and prior sinus surgery. Clarified NMN statement and post-surgical debridement. Updated Rationale and References sections.



MPTAC review. Updated Rationale and References sections.



MPTAC review. Updated formatting in clinical indications section. Updated References section. Removed ICD-9 codes from Coding section.



MPTAC review. Added “consecutive” to the medically necessary criteria addressing antibiotic therapy. Updated References section.



MPTAC review. Updated Rationale and References sections.



MPTAC review. Clarified medically necessary criteria regarding CT findings for uncomplicated sinusitis and allergy assessment. Updated Coding and References sections.



Updated Coding section to remove CPT 31240 (not applicable).



MPTAC review. Revised mucocele indication in MN statement to add “causing chronic sinusitis”. Added “Cavernous sinus thrombosis caused by chronic sinusitis” to MN statement. Updated Coding and References sections.



MPTAC review. Revised statement regarding uncomplicated sinusitis. Revision of debridement statement regarding symptoms of nasal obstruction.



MPTAC review. Added language to not medically necessary section regarding the use of FESS for all other indications.



MPTAC review. Added medically necessary and not medically necessary statements regarding postoperative debridement following FESS. Updated rationale and references.



MPTAC review. Updated References section.



MPTAC review. Updated References section.



MPTAC review.



MPTAC review.



MPTAC initial guideline development.