Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic sinusitis

Treatment: office balloon sinuplasty and turbinate reduction

The insurer denied coverage for office balloon sinuplasty and turbinate reduction

The denial is overturned.

The patient is a male with a history of sinusitis.  The history is described as several years of chronic sinusitis.  He has been treated on multiple rounds of "antibiotics in the past with only temporary relief, he has tried Flonase, saline rinses, over-the-counter antihistamines and feels that the symptoms have been gradually worsening for months ".  The records and the appeal letter further note it is greatly affecting his quality of life and breathing and sleep.  He has frequent headaches and sinus pressure along with postnasal drip.  CAT (computed axial tomography) scan showed mucosal thickening greater than 3 mm (millimeters) with blockage of the ostiomeatal units.  They also describe bilateral inferior turbinate hypertrophy and nasal swelling.  The proposal is for balloon sinuplasty and turbinate reduction.  Office records further note the use of Flonase, saline rinses.  Endoscopic nasal exam was done showing blocked ostiomeatal units and turbinate hypertrophy.  CAT scan report is in the chart showing significant thickening of the frontal sinus, ethmoid sinus, sphenoethmoidal recesses maxillary sinuses and air-fluid level in the sinus.  Medications listed include Zithromax and prednisone oral tablets

There was a denial by the insurance that did not meet criteria.

This patients' records are consistent with fulfilling all typical criteria for sinus surgery.  The patient has had years of sinusitis that has gotten worse in the last 3 months.  The patient has been maximally medically treated with antibiotics, steroid nasal, saline irrigation and antihistamines but still has persistent symptoms.  The patient has a confirming CAT scan showing very significant sinus thickening along with an air-fluid level.  The patient is refractory to treatment and has persistent symptoms that are affecting his quality of life.  Nasal endoscopy confirmed the physical exam complaints.  Balloon sinus surgery is now commonly done by ENT (ear, nose, and throat) physicians and the literature supports its efficacy and its shorter recovery and possibly less complications.  As concluded in a multicenter study by Payne et al "Conclusion: Patients who selected sinus surgery in which BSD (balloon sinus dilation) instruments were used on the peripheral sinuses demonstrated significantly greater improvements in quality of life compared with those who elected ongoing MM (medical management). These results were achieved through office-based procedures with the patient under local anesthesia in the majority of patients."  

Therefore, the procedures are consistent with being medically necessary of sound medical judgment and in the best interest of the patient.

As noted above the procedure is consistent with being medically necessary.  The records show the patient is refractory to medication has persistent symptoms and quality of life issues and confirming CAT scan and nasal endoscopy.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.


The insurer's denial of coverage for office balloon sinuplasty and turbinate reduction, is overturned. Medical Necessity is substantiated.