Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Propel mometasone sinus implant for treatment of the enrollee, who has a history of chronic sinusitis. Findings:  2/3 of the physician reviewers found that the patient has persistent nasal blockage and congestion.  A computed tomography (CT) scan showed extensive ethmoid polypoid sinonasal obstruction.  His medications have included an intranasal antihistamine and nasal steroid combination spray as well as oral levocetirizine and pseudoephedrine. The documentation did not mention any relief obtained with these medications, nor was there any mention of preoperative steroid use demonstrating any benefit or lack thereof to reduce symptoms.  The nasal septum was mentioned to be deviated to the right with some 2+ hypertrophy of the inferior turbinates.  No polyps were mentioned on this examination.  The patient underwent surgical repair of deviated septum, reduction of inferior turbinate hypertrophy, and endoscopic image guided ethmoid, maxillary, sphenoid and frontal recess sinus surgery.  At the termination of the surgery, the provider placed the Propel sinus stents into the ethmoid cavities.  The Health Plan has denied reimbursement for Propel mometasone sinus implant.  Per the Health Plan, the services at issue were investigational for the treatment of this patient.There is a lack of support for the services at issue in this clinical setting.  These sinus implants are impregnated with steroid-eluting material and have demonstrated some improvement in postoperative swelling and reduction of synechiae formation.  However, there is a lack of case controlled, peer-reviewed publications to fully establish the superior efficacy of the services at issue.  Massey and colleagues noted steroid delivery systems may play an increasingly important role in reducing disease recurrence after endoscopic sinus surgery, although more studies are needed to assess long-term outcomes.  Future randomized controlled trials are necessary to assess the benefits of these devices.  Therefore, Propel mometasone sinus implant performed was not likely to have been of greater benefit than other treatment options. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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.