Chronic Sinusitis denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 50-year-old male with a history of chronic sinusitis. He had maxillary advancement surgery in 1982. There is a questioned history of Caldwell-Luc sinus surgery in 1990. In 1992, the patient underwent right-sided functional endoscopic sinus surgery. In 2000, he continued with chronic sinusitis symptoms. Medical therapy has included allergy shots, multiple nasal steroid sprays, Atrovent, Astelin, Singulair, multiple oral antihistamines, oral steroids, Kenalog injections, in addition to multiple antibiotics. The patient subsequently underwent revisional functional endoscopic sinus surgery, septoplasty, and turbinate reduction surgery. Despite multiple surgical interventions and aggressive medical therapy he still continues to experience episodes of sinusitis. He was treated with a course of Rocephin in 2002.

The patient has requested authorization and coverage for nebulized antibiotics. She has a history of acute chronic sinusitis. In October 2002, the patient was found to have left nasal polyps and mucopus on exam. She was treated medically with several courses of antibiotics, including broad-spectrum antibiotics (Avelox and Levaquin), nasal steroid spray, and saline irrigation. A CT sinus scan in December 2002 demonstrated mild chronic changes in all of the paranasal sinuses, most marked in the left maxillary sinus. Turbinate hypertrophy was noted as well. Septal deviation was reported upon examination.In December 2002, the patient underwent septoplasty, left endoscopic maxillary antrostomy, and bilateral inferior turbinate radiofrequency reduction. The pathology report confirmed chronic inflammatory infiltrate. No further infections were documented until December 2003.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Propel mometasone sinus implant for treatment of the enrollee, who has a history of chronic sinusitis. Findings: 2/3 of the physician reviewers found that the patient has persistent nasal blockage and congestion. A computed tomography (CT) scan showed extensive ethmoid polypoid sinonasal obstruction. His medications have included an intranasal antihistamine and nasal steroid combination spray as well as oral levocetirizine and pseudoephedrine. The documentation did not mention any relief obtained with these medications, nor was there any mention of preoperative steroid use demonstrating any benefit or lack thereof to reduce symptoms. The nasal septum was mentioned to be deviated to the right with some 2+ hypertrophy of the inferior turbinates. No polyps were mentioned on this examination.

Nature of Statutory Criteria/Case Summary: An enrollee has requested office balloon sinuplasty (frontal, maxillary, and sphenoid) for treatment of the enrollee’s chronic sinusitis. Findings: Two physician reviewers found that while sinus ostial dilation with balloon sinuplasty is an appropriate therapeutic option for some patients with chronic sinusitis, the criteria have not been met in this patient. The indication for balloon sinuplasty is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration.

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