Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee is a 53-year-old female who has a 4.5-year history of chronic sinusitis with recurrent acute infection. Additionally she has problems with migraine headaches and has been diagnosed with fibromyalgia. An additional compounding factor in this patients care is her stated history of multiple antibiotic allergy. Initial treatment in November 2000 included oral antibiotics and nasal saline irrigation. A CT scan in December 2000 showed near complete filling of the maxillary sinuses with osteomeatal complex obstruction, minimal patchy disease of the ethmoids, clear sphenoids, and undeveloped frontal sinuses. After failure of initial therapy the patient underwent bilateral FESS as well as septoplasty. The surgeon notes the findings of thick fungal material at surgery. However, the pathology report indicates the findings of marked allergic inflammatory exudation and mucous gland hyperplasia. There is no mention of the findings of fungal hyphae and no bacterial cultures were done. Post-operatively the patient had continued frontal headaches and was treated with Tequin, duratuss, Allegra and Flonase. Acute infection with notation of purulent material occurred in June 2001 and cleared with a repeat of treatment with Tequin. For continued postnasal drip and cough the patient was seen by an allergist. Testing for PCN and cephalosporin allergy was negative. For her headaches the patient is followed by a neurologist.Increased symptoms and purulent material were again noted when the patient was seen in January 2002. Cipro drops were added to the patients saline wash in treatment of this infection. Revision FESS and turbinate reduction were done in April 2002 because of continued symptoms. Culture done at this time was positive for Staph, Aureus, sensitive to most antibiotics tested. Recurrent infection occurred in July and continued in August. A repeat CT in September 2002 showed, again, maxillary sinus opacification, partial opacification of the right ethmoid region, opacification of the right sphenoid and clear small frontal sinuses.The enrollee continued over the next several months to have recurrent symptoms and findings of thick crusty discharge from her nose. Her surgeon empirically labeled this pseudomonas and performed in-office debridements. Saline irrigations were continued and treatment with nebulized antibiotics was requested in February 2003. This was denied, but SinuNEB with Cefuroxime was instituted in April 2003, treatment with oral Biaxin occurred in May 2003 and SinuNEB with Cefuroxime was repeated in June. Frontal and facial headaches continued, but other symptoms were improved. OxyContin and Darvocet were being taken for headaches. The patient did well until March 2004 when the headaches recurred. Infection with green crusts found on exam was diagnosed in June 2004. Coprodex saline irrigations were instituted followed by SinuNEB treatment with Levaquin. Although the patient continued to complain of headaches after a three-week course of this latter treatment, the sinuses were noted to be clean on exam. SinuNEB was again prescribed anyway. This has been denied by the Health Plan and the patient has continued to have recurrent infections with green crusty nasal discharge.This patients case is complicated as chronic sinus disease patients often are. This patient has more than one problem. Her headaches are a compounding factor to her sinus disease. Treatment with antibiotics, nebulized or otherwise, should not be given for headaches alone. The patient does have a history of migraine headaches and may actually be having rebound headaches secondary to narcotic use.Aside from this, this patient does have chronic sinus disease with intermittent acute exacerbations. When she actually has purulent discharge this should be cultured from the sinus ostia so that antibiotic therapy may be directed rather than empiric. As this patient has adverse reactions (allergic or otherwise) to multiple oral antibiotics, she does need another mechanism to receive necessary treatment. She is a good candidate for nebulized therapy, as she has had her sinuses surgically opened and has failed other medical therapy. Use of nebulized delivery of antibiotics and other medication have been used for pulmonary purposes and is gaining wider acceptance for use in treatment of sinus disease. Although a fairly new modality for this purpose, recent studies have shown efficacy in these difficult patients. As such, I recommend reversing the Health Plans denial as the disputed care is medically necessary and this patient has little other options. It should not be used, however, unless purulent discharge is documented with culture specific sensitivities. It should not be used in the treatment of headaches alone and should not be used repetitively on an empiric basis.Based upon the information set forth above and based upon the limitations set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plan denial should be overturned.