Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent acute sinusitis
Treatment: Balloon sinuplasty and eustachian tube balloon dilation
The insurer denied the balloon sinuplasty and eustachian tube balloon dilation.
The determination is overturned in part.

This is a female patient with a history of recurrent acute sinusitis (greater than [>] 4 infections/year), chronic sinusitis, nasal obstruction/facial pain and allergic rhinitis. She has tried multiple prolonged courses of antibiotics, with suboptimal response, intranasal corticosteroids, oral anti-histamines, and nasal saline without sufficient improvement in symptoms. A nasal endoscopy demonstrated thick mucoid secretions consistent with chronic sinusitis. Multiple computed tomography (CT) scans of the sinuses were performed at various intervals which showed per report pansinusitis, obstruction of the osteomeatal complexes bilaterally and narrowed frontal-ethmoid outflow tracts. Post treatment CT scan sinuses were then obtained based on insurance requirement. CT sinuses images were reviewed by by the health plan which did not show osteomeatal unit obstruction per clinical review notes. Multiple audiograms and clinical exams were performed which did not demonstrate chronic otitis media with effusion; there have been instances of temporary eustachian tube dysfunction resulting in middle ear effusions/conductive hearing loss secondary to acute sinusitis. Her provider is requesting approval to perform bilateral balloon sinuplasty and eustachian tube dilation. At issue is the medical necessity of the requested procedures.

The services are medically necessary in part. 

The proposed health service/treatment of balloon sinuplasty is medically necessary. The Food & Drug administration approved balloon sinuplasty with appropriate indications in 2005. Given the patient's diagnosis and current health status, the proposed procedure are medically necessary. The patient has received a thorough workup including physical examination, and based on review of treating Otolaryngologist's CT interpretation, CT sinuses have all demonstrated chronic sinusitis. The patient has a history of recurrent acute sinusitis. The patient has undergone maximal medical therapy including undergoing treatment with multiple prolonged courses of oral antibiotics, intranasal corticosteroids, oral antihistamines, without sufficient improvement in symptoms. Allergy testing demonstrated hypersensitivities which is likely a risk factor for underlying chronic sinusitis. The American Academy of Otolaryngology clinical consensus statement (last published in 2018) state that balloon sinus dilation is appropriate as a standalone procedure in patients with chronic sinusitis without polyposis.

The proposed health service/treatment of eustachian tube dilation is not medically necessary. Based on patient medical record documentation and scientific data, the proposed treatment has been proven to be safe and effective for the diagnosis of persistent eustachian tube dysfunction. The patient has not been demonstrated to have consistent clinical findings/exam findings/audiometric findings consistent with chronic otitis media with effusion/eustachian tube dysfunction aside from occurring occasionally secondary to temporary eustachian tube dysfunction secondary to acute sinusitis.

I overturn the determination, in part. I overturn the health plan's determination of medical necessity regarding balloon sinuplasty. I uphold the health plan's determination of medical necessity regarding eustachian tube dilation.