Rhinitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) radiofrequency ablation of the posterior nasal nerve area and/or (2) low-dose radiofrequency intranasal tissue remodeling of the nose. Chronic rhinitis is an inflammatory condition of the nasal cavity, which typically manifests as nasal obstruction and excessive nasal discharge. It can be triggered by allergic stimuli, non-allergic stimuli, or a combination of the two. Standard medical therapies for chronic rhinitis include intranasal corticosteroids, intranasal antihistamines, and intranasal anticholinergics. For cases recalcitrant to medical therapy, surgical options include inferior turbinate reduction, Vidian neurectomy, and posterior nasal neurectomy.

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.

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ClariFix procedure bilateral cryoablation to the mucosal surface. As noted in a comprehensive practice parameter for allergic rhinitis and nonallergic rhinitis developed jointly by the researchers, first-line therapy for both persistent allergic and non-allergic rhinitis includes intranasal antihistamine and/or intranasal corticosteroids. Additionally, the authors found that intranasal antihistamine and intranasal corticosteroid dual therapy is significantly better than intranasal corticosteroid alone in alleviating nasal and ocular symptoms in patients with allergic rhinitis. In a systematic review, an academic study found that cryoablation was effective in reducing symptoms associated with chronic rhinitis.

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