Chronic Rhinosinusitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, trans-nasal or via canine fossa, nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia, and nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior), with the approved submucous resection inferior turbinate, partial or complete, any method. Balloon dilation of the sinuses can be beneficial for patients with either recurrent acute, or chronic rhinosinusitis. Balloon dilation of the sinuses offers a significant benefit over traditional functional endoscopic sinus surgery as it carries less morbidity and can frequently be accomplished in an office setting.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of the components of an endoscopic procedure (bilateral ostial dilation of maxillary sinuses; bilateral balloon ostial dilation of frontal and sphenoid sinuses; and bilateral partial (anterior) nasal/sinus endoscopy, surgical with ethmoidectomy). Balloon dilation of the sinuses (BDS) is typically performed on patients with either recurrent acute rhinosinusitis (RARS) or chronic rhinosinusitis (CRS). BDS offers a significant benefit over traditional functional endoscopic sinus surgery (FESS) as it carries less morbidity and can frequently be accomplished in an office setting. BDS is recommended for patients who meet strict diagnostic criteria for rhinosinusitis and are refractory to maximal medical management, such as intranasal saline, topical steroids, and antibiotics.

Where the denial was upheld

The patient is a 41-year-old male with chronic eye pain and chronic rhinosinusitis. The records provided include multiple notes from several physicians with different specialties. He has had problems with chronic bilateral eye pain (also referred to variously as retro-orbital pain and atypical facial pain) for many years. He has had several surgeries, received neuro-ganglion blocks, and takes oral analgesics on a regular basis for this problem. There are detailed notes related to possible adverse affects experienced by the patient with the use of Neurontin and gabapentin. There are two physician dictations regarding this patient’s sinus disease history. In October 2004 it is noted that the patient had a history of nasal and paranasal sinus polyposis.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures including balloon dilation of the maxillary, frontal, and/or sphenoid sinus ostia and/or turbinate resection. Balloon dilation of the sinuses can be beneficial for patients with either recurrent acute, or chronic rhinosinusitis. Balloon dilation of the sinuses offers a significant benefit over traditional functional endoscopic sinus surgery as it carries less morbidity and can frequently be accomplished in an office setting. Balloon dilation of the sinuses should only be recommended to patients who meet the criteria for the diagnosis of rhinosinusitis and who are refractory to maximal medical management including the use of intranasal saline, topical steroids, and antibiotics.

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 chronic rhinosinusitis, then check the rights and deadlines that apply to your plan.