Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic sinusitis, Deviated nasal septum, Pathologic obstructive right concha bullosa, Bilateral hypertrophic inferior turbinates, Internal nasal valve vestibular stenosis
Treatment: Endoscopic Sinus Surgery
The insurer denied coverage for Endoscopic Sinus Surgery.
The denial is overturned.

This is a male patient with a past medical history of diabetes, sleep apnea, chronic sinusitis, deviated nasal septum, pathologic obstructive right concha bullosa, bilateral hypertrophic inferior turbinates, and internal nasal valve vestibular stenosis. The patient has been treated conservatively. He presented with severe facial pain, sinus pain and pressure, headache, nasal blockage, eustachian tube dysfunction, and an altered sense of smell that had worsened over the past two years in the setting of recurrent sinus infections. The patient complained of worsening sleep apnea and sleep disordered breathing that correlated directly with his escalated nasal sinus symptoms and nasal obstruction, making continuous positive airway pressure (CPAP) usage difficult. He has been treated with antibiotics and the infections he had would respond in the past. The patient's condition had worsened with chronic sinusitis infections not responding to a number of antibiotics. He could not tolerate Allegra and Claritin because of the sedating effects that worsened his sleep apnea. He had failed steroid nasal sprays and saline irrigations. The symptoms were recalcitrant.

 A nasal endoscopy revealed a severe left nasal septal deviation extending to the dorsum of the nose with S-shaped deformity. A computed tomography (CT) scan of the sinuses confirmed nasal airway compromise and obstruction. There was severe nasal airway narrowing. The patient underwent a CT navigational image guided endoscopic resection of pathologic right obstructive concha bullosa, septoplasty, endoscopic resection of bilateral inferior turbinates and, open endonasal repair of vestibular stenosis with bilateral spreader grafts and suture suspension for the diagnoses of chronic sinusitis, deviated nasal septum, pathologic obstructive right concha bullosa, bilateral hypertrophic inferior turbinates, and internal nasal valve vestibular stenosis.

Scientific evidence in peer reviewed literature supports a result of improvement in outcomes in chronic sinusitis when treated with functional endoscopic sinus surgery.  These procedures are all approved treatments for patients with chronic sinusitis that have not responded to medical management. The patient was a good candidate for endoscopic sinus surgery. He had symptoms of chronic sinusitis which had not improved with multiple antibiotics, nasal steroids or antihistamines.  Functional endoscopic sinus surgery is an appropriate treatment for patients with chronic sinusitis of the involved sinuses that has not improved with appropriate medical management.   

These procedures are more likely to be beneficial than any of the other standard treatments for this patient who already failed to improve with the standard medical treatments. Since the patient was concurrently being treated for septal deviation and nasal vestibular stenosis in the operating room, it was appropriate to treat the sinuses at the same time.  

The carrier's denial of coverage for Endoscopic Sinus Surgery should be overturned.