Sinusitis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for PROPEL sinus implants utilized during sinus surgery. Findings: The physician reviewer found that FESS, surgical outcomes can be compromised in the immediate post-operative period by scarring, adhesion formation, and early polyp recurrence. Oral and topical corticosteroid therapy are standard treatments for the maintenance of successful surgical outcomes, the management of post-operative scarring and edema, and the prevention of nasal polyp recurrence. Shen and colleagues report that clinical evidence has demonstrated the safety and efficacy of steroid-eluting sinus implants in the reduction of polyp size, symptom burden, and the need for revision sinus surgery.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the brain sinuses without contrast. Chua and colleagues note that MRI is more specific than computed tomography (CT) in characterizing unilateral maxillary sinus opacification, with greater diagnostic certainty and reproducibility. The authors further note that the additive diagnostic value of MRI complements CT, potentially reducing diagnostic delays in some cases and the need for diagnostic endoscopic sinus surgery in others. Alves and colleagues note that CT and MRI are commonly used in evaluation of paranasal sinuses and that description of such findings by a radiologist can lead to a change in treatment strategy. In this case, the patient had a history of severe facial pain, perhaps due to a dental abscess, and underwent an MRI for evaluation.

Where the denial was upheld

A 45-year-old male enrollee has requested coverage for past emergency services provided. Findings: The physician reviewer found that the patient presented to the emergency room (ER) with complaints of a runny nose, nasal congestion, and a cough for one week. The cough was productive of scanty, yellow sputum, and the patient noticed a fever two hours prior to admission to the ER, which resolved with the use of Advil administered at home. His vital signs in the ER were normal except for slightly elevated blood pressure at 139/81, and his pain level was 2 on a scale of 1 to10. No diagnostic testing was performed in the ER. The provider assessed the patient with allergic rhinitis, sinusitis, and cerumen impaction. He was given prescriptions for the antibiotic Zithromax plus Zyrtec, Sudafed, and Motrin for his symptoms and discharged from the ER.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) of the sinuses and/or CT of the chest. The records provided for review document that this patient presented with four weeks of symptoms including chest congestion, cough, frontal and temporal headache, nasal congestion, sore throat and upper back pain. The patient’s headaches were noted as sinus and located in both sides of her temples. Treatment has included acetaminophen, as well as Treatment with Vantin and Sudafed, which have provided some improvement in symptoms. The records mention a previous hospitalization for migraine. The visit was telemedicine with no physical examination. The provider has recommended CT imaging of the sinuses and chest.

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