Balloon Ostial Dilation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for balloon ostial dilation procedure. In this case, the patient has chronic sinusitis. Chronic sinusitis is an inflammation in the sinuses, lasting longer than 12 weeks, that may be caused by infections, allergies, anatomic problems, or a combination of some or all of these. Chronic sinusitis may be medically managed, as in this case. Endoscopic sinus surgery (ESS) is an option once medical management has been tried and failed. Researchers report the symptomatic improvement for recurrent acute rhinosinusitis, chronic sinusitis, or both, following ESS. In a systematic review and meta-analysis, researchers noted that ESS significantly improved objective endoscopic scoring outcomes over continued medical therapy alone.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for bilateral balloon ostial dilation.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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation for treatment of the enrollee's nasal congestion and sinus pressure.Findings: All three physician reviewers found that while sinus ostial dilation, even by balloon sinuplasty, is an appropriate therapeutic option for patients with chronic sinusitis, the criteria for this patient has not been met. The indication for balloon sinuplasty (balloon ostial dilation) is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 weeks consecutive duration.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon ostial dilation. Findings: Three physician reviewers found that the records noted a history of posterior nasal discharge and an episode of presumed rhinosinusitis 2.5 months previously which had been medically managed with appropriate therapy. The patient had no clinical evidence of chronic sinusitis. The single report of the objective finding of the computed tomography (CT) scan from 2018 did not show evidence of chronic sinus problems, as there was no clinical evidence of opacification of any of the paranasal sinuses, and the ostiomeatal units were open, not obstructed. The nasal endoscopy suggested no evidence of any acute sinus problems. The only physical finding was that of a moderate deviated nasal septum, which is not treated with balloon sinus ostial dilation.

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 Balloon Ostial Dilation, then check the rights and deadlines that apply to your plan.