Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep disturbance, nasal congestion. 
Treatment: Vestibular stenosis repair and absorbable nasal implant. 

The insurer denied the Vestibular stenosis repair and absorbable nasal implant. 
The denial is overturned. 

The patient is a female. Telehealth evaluation indicates long-standing insomnia, mouth breathing, and stuffy nose - worse on the right and discussion of septoplasty and inferior turbinate reduction. 

Evaluation notes sleep disturbance, nasal congestion, postnasal drip, symptoms present year-round; medications include Flonase; allergy testing was positive; examination indicates nasal congestion; assessment of allergic rhinitis; plan to continue Flonase and start Zyrtec as needed. 

Evaluation notes difficult right nasal breathing, insomnia, no apnea.  The Flonase was not helpful.  Examination revealed septal deviation, enlarged left inferior turbinate.  Plan was for septoplasty and inferior turbinate reduction. 

Evaluation notes long-standing difficult nasal breathing, nasal strips with some benefit, seasonal environmental allergies, insomnia, and nasal symptom score 70/100.  The patient had a previous trial of nasal steroid sprays without  benefit.  The computed tomography (CT) scan was noted to show right septal deviation, septal spur, bilateral inferior turbinate hypertrophy, and mucosal disease of the left maxillary sinus.  The patient's examination indicated a prominent dorsal hump, right nasal septal deviation with inferior spur, right nasal valve collapse, and positive Cottle maneuver.  Assessment was septal deviation, inferior turbinate hypertrophy, and sleep disturbance.  Surgical treatment was discussed. 

Operative note notes septoplasty, bilateral inferior turbinate coblation and outfracture, bilateral placement of Latera nasal implant for diagnoses of chronic nasal obstruction, sleep disturbance, deviated nasal septum, nasal valve collapse, and bilateral inferior turbinate hypertrophy. The external review is for vestibular stenosis repair with Latera. 

The reason for denial on prior review was that there is no nasal obstruction caused by defect of the nasal valve, no documentation of nasal valve collapse, no documentation that other causes of nasal obstruction were ruled out, no photo documentation, examination findings of septal deviation and spur, and that the peer-reviewed medical literature was insufficient to show that absorbable nasal implants are effective treatment for vestibular stenosis. 

Yes, the treatment of vestibular stenosis repair with Latera was medically necessary. 
In this case, there is documentation in the available medical record of nasal congestion affecting quality of life, failure of medical therapy, examination findings of nasal vestibular stenosis contributing to the cause of symptoms, and preoperative photo documentation. 

Per the American Academy of Otolaryngology Position Statement: 
The AAO-HNS acknowledges the benefit of use of absorbable nasal implants for nasal valve collapse, based on currently available data. Patients with nasal valve collapse commonly suffer from nasal obstruction. When patients are identified with nasal valve narrowing or collapse, they benefit from procedures intended to strengthen and support the lateral nasal wall. The placement of absorbable nasal implants offers patients a safe and effective treatment for nasal valve obstruction. 

Per the American Medical Association (AMA) definition of "medical necessity" (Policy H-320.953[3], AMA Policy Compendium): 
Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider. 

Vestibular stenosis repair with Latera is: 
(1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in denying the vestibular stenosis repair and absorbable nasal implants as they are medically necessary.