Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Other - Chronic Eustachian Tube Dysfunction
Treatment: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 

The health plan denied: Nasal and/or sinus endoscopy surgical with dilation (eg balloon dilation) maxillary, frontal and sphenoid sinuses (sinus surgery) 
The determination is: Overturned

The patient is a female who has a history of sinusitis and has a request from the physician for nasal endoscopic surgery balloon dilation of the maxillary, frontal, and sphenoid sinuses. Medical records indicate the patient has had a sinus infection for which she was given antibiotics but continued to have sinus pain. She has a history of prior sinus infections. She is using Zyrtec, Flonase, and Nettie pot daily. There is a computerized axial tomography (CAT) scan report within the record. It is indeterminant if this CAT scan was done in the office or elsewhere, and they compared it to a CAT scan done a year prior, in which it "shows no improvement." The CAT scan also shows findings of "frontal left and right mild opacification, right maxillary mucous cyst and opacification, stenotic ostiomeatal complex, left sinus 3 to 5 millimeter (mm) opacification, ostia is stenotic, sphenoid minimal, opacification bilaterally." The records further notes she was seen previously a year ago for recurrent sinus infections and "not responding to antibiotics, and she has had allergy shots." She "continues to experience sinus infections requiring antibiotics...Facial pain and pressure on a daily basis." There are prior notes showing the allergies and sinus issues, along with a long list of medications and the reported CAT scan showing sinus opacification.
The requested surgery appears to be frontal sphenoid maxillary sinus surgery with balloon dilation.
At issue is whether the proposed health service or treatment is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is overturned in whole.
The proposed health service or treatment is likely to be more beneficial than any standard treatment for the patient's condition. This patient has a well-documented history of chronic sinusitis. There are records going back to over a year ago. She has been on multiple antibiotics, Zyrtec, Flonase, and Nettie pot. She has been allergy tested and treated. She has had 2 CAT scans done, both of which show maxillary, frontal, and sphenoid opacification and partial narrowing of the ostia of the maxillary sinus.
Balloon sinus surgery is a minimally invasive technique for the treatment of appropriate patients with sinusitis. The procedure is Food and Drug Administration (FDA) approved. The procedure has been used since approximately 2005. The procedure is widely accepted in the ear, nose, and throat (ENT) community and is considered a standard of care for appropriate patients. It is widely accepted by most insurances. The American Academy of Otolaryngology statement on balloon sinus dilation says "the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS), with approximately 12,000 members nationwide, is the national medical association of physicians dedicated to the care of patients with disorders of the ears, nose, throat, and related structures of the head and neck...he AAO-HNS supports the use of a balloon as a tool in a standard approach to sinus ostial dilation along with other indicated endoscopic surgery, and strongly encourages all payers to consider its use as a covered service. We remain concerned with payer policies that designate stand-alone ostial dilation as 'experimental/investigational' and/or 'not medically necessary' given of the significance of the available evidence indicating the contrary." There are numerous articles in the literature in support of balloon sinus surgery. The balloon sinus surgery is consistent with standard practice by ENT physicians, most insurances, the literature, its FDA approval, and its support by the American Academy of Otolaryngology.
The proposed treatments are more beneficial than standard treatment for the patient's condition. Endoscopic sinus surgery balloon dilation is consistent with being shown in the literature to be efficacious and with reduced complications and postop issues.