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

Nature of Statutory Criteria/Case Summary: A 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patients medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown. The management of chronic rhinosinusitis with nasal polyps, aimed at improving these symptoms, includes both surgical and medical treatments, but there is no universally accepted management protocol. A study indicates it is necessary to have at hand a current and appropriate CT scan for planning of the actual surgical project. For this patient, there were conflicting notes about the presence of polyps on endoscopy; and a CT scan did not support the diagnosis of obstructing polyposis or evidence of sinusitis.Additionally, while functional endoscopic sinus surgery (FESS) can be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis; the criteria have not been met in this patient.  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 weeks 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 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. Chronic rhinosinusitis was not documented in this patient: there was no documentation of 12 weeks of consecutive disease. Recurrent acute sinusitis was not documented in this patient: there was no documentation of four or more recurrent episodes with complete clearing of symptoms between episodes over a one-year period. There was no documentation of chronology of disease, symptoms or treatment or documentation that she was treated with maximal medical therapy prior to the CT scan. There was no evidence of sinus disease on the CT scan or documentation of findings of nasal endoscopy suggestive of sinus disease. Therefore, functional endoscopic sinus surgery is not medically necessary in this patient.However, according to the AAOHNS, indications for septoplasty include nasal obstruction secondary to septal deviation, refractory to medical management or for surgical access. There was documentation of septal deviation, nasal obstruction and failed medical management. Therefore, septoplasty is medically necessary in this patient.Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in plastic surgery within the head and neck 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.