Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic sinus headaches 
Treatment: Computed tomography of the orbit (current procedural terminology code 70480) 

The insurer denied coverage for computed tomography of the orbit (current procedural terminology code 70480). The denial is upheld. 

This patient is a female who was seen by otolaryngology (ENT) physician with complaints of chronic sinus headaches that have not responded to medication.  The patient stated that she has had this pain for over a year, and that a light touch gave her bruising sensation.  The patient was noted to have trialed and failed Flonase as well as antibiotics and Imitrex.  The patient stated there was no other, associated pain.  The patient's past medical history was significant for allergic rhinitis and essential hypertension.  As per ENT comments, the patient had point tenderness with palpation of her right upper eyelid; and that though the patient reports feeling some pressure on her right eye, she does not feel pain unless the right eye is touched.  The comment documents that the patient had an eye examination and was told her eyes were normal and without swelling.  The ENT physician documents that that the patient rates the pain 3/10, and that the physician is unclear as to the etiology of the pain.  The physician documents that differential diagnosis includes neurologic, related to the patient's lacrimal gland or sinus; and recommends for an orbital scan of the right eye.  As per recommendation, the patient underwent the requested CT scan for which the results showed no intracranial or extracranial masses identified.  

This patient was seen with complaints of chronic headaches that have not responded to medication.  However, other than pain upon palpation of the upper eyelid of the right eye, the patient presented with no physical abnormalities.  Based on the literature review, computed tomography (CT) of the orbit is medically indicated if the patient who presents with any of the following conditions: open globe; intraocular or orbital foreign body; orbital fracture, especially in patients with impaired extraocular motility or proptosis, and/or ocular compartment syndrome (after lateral canthotomy and cantholysis).  If the provider had suspected intraocular or intracranial infection secondary to sinusitis, literature supports the use of computed tomography (CT) or magnetic resonance imaging (MRI) of the head, including the paranasal sinuses.  Based on the review of the medical record, the patient's physician's differential was neurologic, related to the patient's lacrimal gland or sinus.  This working diagnosis does not support the requested orbital CT scan.  

The CT scan is performed to confirm a diagnosis made on physical exam and history.  It is also performed in preparation for surgical intervention.  However, in this case, there were no physical findings to warrant a CT scan, and there was no indication that the patient was a surgical candidate.  There was also no indication of significant findings on examination that would warrant a diagnostic imaging with an orbital CT scan.  
	
The health plan acted reasonably with sound medical judgment in the best interest of the patient.  

The carrier's denial of coverage for the computed tomography of the orbit (current procedural terminology code 70480) is upheld.  The medical necessity is not substantiated.