Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (CPT code 31295), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says that the information received indicates that the enrollee has had symptoms for several months, but the enrollee's computed tomography (CT) scan results do not indicate that you have chronic sinusitis; therefore, this procedure is considered not reasonable and necessary and will not be covered by your insurance.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the request for balloon sinuplasty is medically reasonable and necessary. The enrollee reported chronic nasal obstruction and facial pressure, had mucoid drainage and crusted nasal secretions, and demonstrated signs of inflammatory disease with resultant mild narrowing of the bilateral ostiomeatal complexes on CT imaging, which overall appears to meet the definition of chronic rhinosinusitis (CRS) according to the 2015 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline on adult sinusitis. Sinus ostial obstruction is one of several key CRS-related abnormalities that the AAO-HNSF guideline states are best seen on CT. Moreover, the expert panel on the 2018 AAO-HNSF clinical consensus statement on balloon sinus dilation achieved consensus on statement #2 ("Balloon dilation is not appropriate for patients with sinonasal symptoms and a CT that does not show evidence of sinonasal disease"). The enrollee exhibited both sinonasal symptoms and a CT with evidence of maxillary sinus disease (ostiomeatal complex narrowing from mucosal thickening). Given the above findings in available clinical documentation, the use of balloon sinuplasty does appear to be indicated for the enrollee's symptoms. In summary, balloon sinuplasty is medically reasonable and necessary to manage the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have been met. Therefore, we decided that the Plan has to pre-approve nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (CPT code 31295), for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.