Ear-Nose-Thro Proc denials in California external review
In the California DMHC record, independent physician reviewers decided 490 published external-review cases involving ear-nose-thro proc and overturned the plan’s denial in 51.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| medical necessity | 283 | 61.1% |
| experimental / investigational | 203 | 37.9% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Other | 237 | 46% |
| Sinus Surgery | 155 | 63.9% |
| Septoplasty | 36 | 61.1% |
| Cochlear Implant | 28 | 32.1% |
| Tonsillectomy | 23 | 21.7% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 283 | 61.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 203 | 37.9% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 4 | 50% |
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 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patient’s medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) procedure (CPT code 43210) and anesthesia for upper gastrointestinal endoscopic procedures (CPT code 00740) for treatment of the enrollee’s gastroesophageal reflux disease (GERD). Findings: 2/3 of the physician reviewers found that the efficacy of TIF has been studied in randomized controlled trials. One large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures including balloon dilation of the maxillary, frontal, and/or sphenoid sinus ostia and/or turbinate resection. 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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this category of care generally, not any individual case.
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 ear-nose-thro proc, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY