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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral nasal and sinus surgery. While sinus surgery may be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, in this case, the patient does not meet the criteria for the requested service. The American Academy of Otolaryngology  Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12-week consecutive duration. CRS is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or computed tomography (CT) presence of mucosal thickening or air fluid levels in the sinuses. The AAOHNS defines recurrent acute sinusitis as four or more recurrent episodes of  acute rhinosinusitis with complete clearing of symptoms between episodes over a one year period. In this case, the records do not document CRS or recurrent sinusitis. In this case, the submitted records did not document 12 weeks of consecutive disease, or four or more recurrent episodes over a one-year period. There was no documentation of chronology of disease, symptoms, or treatment. There was no documentation that the patient was treated with maximal medical therapy prior to the MRI, which noted only a retention cyst and possible polyp. Therefore, sinus surgery is not medically necessary for the treatment of this patient.  The records did not report nasal obstruction secondary to septal deviation and turbinate hypertrophy, refractory to medical management. There was no recent physical examination documenting septal deviation and turbinate hypertrophy. The patient had undergone several septal procedures in the past, and the records noted overly resected inferior turbinates. There was no report of failed medical management. Therefore, septoplasty and turbinate reduction surgery are not medically necessary for the treatment of this patient. The submitted records documented previous operative treatment of nasal valves and septal bodies. However, the records did not include a recent physical examination documenting nasal valve collapse and obstructing septal swell bodies, or of anatomical deformities contributing to nasal valve collapse. Therefore, nasal valve repair and treatment of nasal lesion are not medically necessary for the treatment of this patient. Therefore, bilateral nasal and sinus surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology  head and neck surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.