Allergic Rhinitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for sinus surgery (nasal/sinus endoscopy, surgical, with destruction by cryoablation, posterior nasal nerve (PNN) and/or nasal/sinus endoscopy, surgical with destruction by radiofrequency ablation, posterior nerve with the approved septoplasty). The records reflect that the patient suffered from vasomotor rhinitis, also known as non-allergic rhinitis, as well as allergic rhinitis. Symptoms of both include rhinorrhea, postnasal drip, nasal obstruction, which are thought to occur from autonomic nerve dysregulation particularly in the case of vasomotor rhinitis.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pollen and allergy injections performed weekly for treatment of the enrollee’s allergic rhinitis and asthma. Findings: The physician reviewer found that based on the available documentation, the service of immunotherapy dosed at once weekly intervals meets the current criteria for medical necessity and is within the standard of care for providing immunotherapy injections to a patient who is symptomatic with asthma and allergic rhinitis. Review of the record shows sufficient documentation to support the increased dosing. There was allergy skin testing done with positive findings for several allergens. Clinic notes from provider indicate that the patient was actively taking multiple medications for rhinitis and asthma.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an allergy skin test. Seidman and colleagues explain that allergic rhinitis is one of the most common disease affecting adults. Clinical practice guidelines report that a diagnosis of allergic rhinitis begins with a directed history and physical examination particularly noting pattern, chronicity, and triggers of symptoms. In this case, the patient has symptoms of intermittent cough, shortness of breath, scratchy throat, and postnasal drip. The records document prior treatment with allergy shots directed by a prior positive skin test, and allergies to tree pollen, weed pollen, dust, and dog dander. The patient had been off all medications since completing allergy shots in 2015.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a rhinoplasty primary with major septal repair. This patient has a history of long-standing allergic rhinitis for over 20 years. There is a lack of report or documentation of failure of recent, medically supervised conservative nasal therapy. Physical examination shows only mild tip ptosis and mild septal deviation. The statement by the provider that operative treatment of mild deformity would have an outsized or marked effect in the presence of intranasal swelling is unsupported by peer-reviewed medical literature. Overall, there is a lack of support for the use of the requested procedure in the peer-reviewed medical literature.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving allergic rhinitis, then check the rights and deadlines that apply to your plan.