Diagnosis: Chronic Rhinosinusitis.
Treatment: 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa.

The insurer denied coverage for for 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa.

The denial is overturned.

This patient is a male with a history of chronic rhinosinusitis. He has complaints of headaches and congestion. He has had a poor response to medications over one year. A balloon angioplasty was requested. Computed tomography (CT) imaging of the sinus demonstrated pan sinusitis with extensive mucosal thickening and obstruction of sinusitis at the ostiomeatal units. He had a complete audiogram which was normal.

The health care plan did not act reasonably and with sound medical judgment or in the best interest of the patient.

The claimant has chronic sinusitis confirmed on imaging and has failed medical management. Balloon sinuplasty is an indicated, non-experimental/investigational, next step in his treatment. It is within generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.

The 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa is considered medically necessary for this patient.

The claimant has chronic sinusitis confirmed on imaging and has failed medical management. Balloon sinuplasty is an indicated, next step in his treatment.

"Balloon sinuplasty is an option in the treatment of sinusitis that has failed appropriate medical therapy. Evidence is best for limited disease in patients with CRS without nasal polyps (CRSsNP) affecting the frontal, sphenoid, and maxillary sinuses. Because BSD can be performed in the office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia." (Cingi et al., 2019).

The requested procedure(s) is within generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards, and associations.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for 31295 nasal/sinus endoscopy, surgical, with dilation (eg balloon dilation); maxillary sinus ostium, transnasal or via canine fossa is overturned. Medical Necessity is substantiated.