Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic sinusitis
Treatment: FESS (functional endoscopic sinus surgery)
The insurer denied the FESS (functional endoscopic sinus surgery).
The denial is overturned.

The patient is a male with chronic sinusitis. His CT (computed tomography) scan reveals mild mucosal thickening of maxillary and sphenoid sinuses, moderate frontal sinus thickening, mild scattered ethmoid thickening, opacified right frontoethmoid and sphenoethmoid regions, and deviated septum. The patient's exam revealed deviated septum, thick mucous and turbinate hypertrophy.

Medical management has included three courses of antibiotics (Bactrim, Omnicef, Augmentin) and astelin.

Yes, the requested functional endoscopic sinus surgery is medically necessary.

The request is medically necessary. The patient has had more than 12 weeks of symptoms and has failed medical management. There is CT scan evidence of chronic sinusitis.

The patient has documented chronic sinusitis refractory to medical management with noted sinus disease on CT scan.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has chronic sinusitis refractory to medical management. The request is considered standard of care. There are no reasonable medical alternatives.

Chronic rhinosinusitis is a clinical diagnosis with the most common symptoms being congestion, facial pain-pressure, hyposmia, and nasal discharge. These symptoms are relatively non-specific, thus diagnosing requires demonstration of inflammation either via endoscopy or imaging. The AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) Clinical Indicators (see reference) advocate for sinus surgery for Chronic Rhinosinusitis when patient has "persistent symptoms and objective evidence of disease by endoscopic and/or CT [computed tomography] imaging that is refractory to maximal medical treatment." Maximal medical therapy is the first line treatment and it includes, but is not limited to antibiotics, nasal steroids, oral steroids anti-histamines, nasal lavage, and possible allergy assessment. The definition of maximal medical therapy is not widely accepted but most otolaryngologist would include but not limit to nasal saline rinses, oral antihistamines, nasal steroids, nasal anti-histamines, prolonged antibiotics, and possible allergy evaluation. Often patients with chronic sinusitis with or without nasal polyposis need extended courses of antibiotics (up to 3 weeks or more).

Per the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery), maximal medical therapy is defined as: Oral antibiotics of 2-4 weeks duration for patients with chronic rhinosinusitis (culture-directed if possible), Systemic and/or topical steroids (at the discretion of the physician), Saline irrigations (optional), Topical and/or systemic decongestants (optional, if not contraindicated), Treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy (at the discretion of the physician) (see AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] sinus surgery indicators).