Nasal Air Obstruct denials in California external review
In the California DMHC record, independent physician reviewers decided 33 published external-review cases involving nasal air obstructand overturned the plan’s denial in 42.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for nasal air obstruct
| Category | Decisions | Overturned |
|---|---|---|
| Sinus Surgery | 9 | 44.4% |
| Septoplasty | 6 | 50% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 23 | 52.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 20% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repair of the vestibular stenosis to be performed along with a septoplasty and turbinate reduction. The requested treatment for this patient is the repair of nasal valve collapse (NVC), specifically to be performed concurrently with nasal septoplasty and bilateral inferior turbinate reduction. NVC results from structural incompetence of the external and/or internal nasal valve, which leads to dynamic obstruction of the nasal vestibule during inspiration. One systematic review and meta-analysis found that their results support the effectiveness of nasal valve surgery in treating NVC. A prospective nonrandomized study evaluated the use of bioabsorbable implants for the correction of NVC.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rhinoplasty for treatment of the enrollee’s nasal injury.Findings: The physician reviewer found that based on the patient’s complaints and review of the photographs, rhinoplasty consisting of external nasal bony work is supported as medically necessary for treatment of this patient’s nasal fracture and reconstructive in nature. The patient presents with an abnormal condition as the result of nasal trauma. The patient has nasal deformity and nasal airway obstruction as a direct result of the previous nasal fracture. As noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is “performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for nasal valve repair with subcutaneous/submucosal lateral wall implant(s). Nasal valve collapse (NVC) refers to either dynamic or static narrowing of the nostrils and leads to a sensation of impeded nasal airflow. As NVC is an anatomic obstruction, medical therapy, such as topical medicated nasal sprays, does not play a significant role in its management. The standard management for NVC includes surgical placement of a cartilage graft in the area of narrowing or weakness. Two randomized controlled clinical trials in 2018 and 2019, respectively, established the safety and efficacy of absorbable nasal implants (ANIs) for the treatment of patients with lateral nasal wall (LNW) insufficiency and patients with dynamic NVC.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the balloon sinus ostial dilation for treatment of the enrollee’s nasal obstruction and chronic sinusitis. Findings: The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. This patient reportedly had symptoms of recurrent acute rhinosinusitis with multiple episodes that was partially controlled with medications, but the symptoms recurred. The physical examination and CT imaging confirmed evidence of nasal septal deviation and mucous membrane thickening within the maxillary sinus with presence of a sinus cyst.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 nasal air obstruct, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY