Balloon Sinus Ostial Dilation 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 balloon sinus ostial dilation. Findings: 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 computed tomography (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).

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for balloon sinus ostial dilation with the approved procedure, submucous resection of the inferior turbinate. Based on the medical records, this patient has a history of chronic sinusitis, which can be caused by infections, allergies, anatomic problems, or a combination of some or all of these. Management of chronic sinusitis can be performed medically, as was done in this patient. Once that is failed, endoscopic sinus surgery can be considered. Studies have demonstrated symptomatic improvement for recurrent acute rhinosinusitis or chronic sinusitis after endoscopic sinus surgery.

Where the denial was upheld

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.

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the balloon sinus ostial dilation provided. Findings: The physician reviewer found that according to the American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) chronic rhinosinusitis is defined as a persistent inflammatory disorder of the paranasal sinuses with symptoms of persistent facial pain, discolored nasal discharge, and symptoms that are refractory to appropriate medical management including antibiotics, nasal anti-inflammatory medications and decongestant therapy. Additionally, computed tomography (CT) scan imaging usually demonstrates extensive mucous membrane changes within the ethmoid, maxillary and other paranasal sinuses with blockage of the ostiomeatal complex.

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