Balloon Sinuplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a balloon sinuplasty procedure. Chronic rhinosinusitis (CRS) is an inflammatory condition of the nasal cavity and paranasal sinuses lasting greater than 12 weeks in duration. The diagnosis is established via a combination of reported symptoms such as facial pain/pressure, nasal obstruction and discharge, and correlative findings on CT. Management of CRS is divided into medical and surgical management. Treatment typically begins with medical therapy in the form of saline irrigations, topical nasal steroids, and antibiotics, with or without oral corticosteroids. Patients that fail to show appropriate improvement in symptoms may then be candidates for functional endoscopic sinus surgery (FESS).

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the bilateral balloon sinuplasty of the frontal, maxillary and sphenoid sinuses (CPT 31295 x 2 and 31298 x 2) that was performed. The Health Plan has denied the service at issue as experimental or investigational for treatment of the enrollee’s chronic rhinosinusitis (CRS).Findings: Two out of three physician reviewers found that According to the American Academy of Otolarygology-Head and Neck Surgery (AAO-HNS) official policy statement, sinus ostial dilation (e.g. balloon ostial dilation) is a therapeutic option for selected patients with CRS who have failed appropriate medical therapy. Clinical diagnosis of CRS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT of the paranasal sinuses.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinuplasty. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline defines chronic rhinosinusitis (CRS) as the presence of two or more symptoms, including mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell, plus inflammation that is documented by mucus or edema in the middle meatus or anterior ethmoid region, sinonasal polyps, and/or radiographic imaging showing paranasal sinus inflammation lasting more than 12 weeks.

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