Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 32-year-old female who is requesting authorization for an MRI of the sinuses. She states that her symptoms began over two years ago after she was hit in the right side of her nose. She questioned whether an old nasal fracture might have been missed. The patient complained of rhinorrhea and sneezing. In August 2004 her otolaryngologist diagnosed severe allergies and nasal polyps. The patient also has a history of asthma. The patient has been treated with ZytecD and referred for an allergy evaluation. A sinus CT performed in October 2004 documented extensive mucosal thickening throughout all the paranasal sinuses, septal deviation, and probable nasal polyposis. Her otolaryngologist made a referral to tertiary care for endoscopic sinus surgery in November 2004.  The patients last allergy testing was performed in December 2004, which documented environmental allergies, and allergy shots were initiated. An ENT surgeon performed bilateral endoscopic ethmoidectomy, maxillary antrostomy, septoplasty, and inferior turbinate reduction surgery in December 2004.Despite surgery and medical therapy that included nasal steroids, antihistamines, Singulair, Astelin, and decongestants, the patient still complained of congestion, rhinorrhea, cough, and itchy throat and eyes. She continued to have recurrent sinus infections requiring antibiotic therapy. The patients ENT surgeon obtained a postoperative sinus CT scan in June 2005, which showed extensive mucosal thickening and suggested her sinus disease had worsened.The patient requested and received a second otolaryngology opinion.   Nasal endoscopy was performed. The CT films were reviewed resulting in a recommendation for revisional sinus surgery.  The patient has also requested an MRI of the sinuses. This request has been denied by the Health Plan because it is not considered medically necessary to evaluate the patients condition. An MRI has not been requested by either of the patients otolaryngologists.Success in endoscopic sinus surgery occurs in 85-95% of patients. Approximately 5-15% of patients require revisional surgery. This patient has severe allergies, nasal polyps, asthma, and extensive paranasal sinus disease. She is in a subgroup of patients with complex disease components who have a much higher rate of recurrent disease and associated symptoms.Simple nasal mucosal problems may respond to medical treatment with long-term antibiotics, steroids, or antifungal and antibiotic nasal irrigation. Patients who have problems involving mechanical obstruction or who have failed repeated courses of medical therapy often require surgery.  In order to fully evaluate a patient who has failed initial sinus surgery, nasal endoscopy and CT scanning are very important and necessary to aid in decision making regarding revisional surgery.  MRI scanning is not generally beneficial in this evaluation with rare exceptions. Those exceptions include evaluation of the frontal sinus after frontal sinus obliteration surgery, evaluation of a possible encephalocele that may mimic a nasal polyp, or evaluating for intracranial extension of an invasive fungal sinusitis or an inverting papilloma. Based on the records provided in this case, there is no clinical indication for an MRI of the sinuses. Therefore, I have determined the requested diagnostic procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.