AllMed Webinar Presents Latest Information To Health Plans On The Medical Necessity of Balloon Sinuplasty

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AllMed webinar provides in-depth review of the latest standards of medical necessity for Balloon Sinuplasty

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Despite recent advances in instrumentation and technology, the management of chronic sinusitis remains challenging for both physicians and patients, especially as treatment guidelines and recommendations continue to evolve.

Despite recent advances in instrumentation and technology, the management of chronic sinusitis remains challenging for both physicians and patients, especially as treatment guidelines and recommendations continue to evolve. During a recent AllMed Webinar, Dr. Michael Dorsen, AllMed’s Medical Director, discussed the latest issues related to determining medical necessity of balloon sinuplasty.

In his presentation, Dr. Dorsen began with an overview of chronic sinusitis, providing a closer look at risk factors and medical treatment options. He described two of the most commonly performed surgeries for chronic sinusitis—functional endoscopic sinus surgery (FESS) and balloon sinuplasty, which is also known as balloon sinus dilation. “The goals of surgery,” he said, “are to re-establish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system, as well as to restore the functional integrity of the inflamed mucosal lining.”

Dr. Dorsen emphasized the importance of taking an appropriate patient history, as the symptoms of chronic sinusitis vary in severity and prevalence and may be subtle, which make diagnosis easy to miss. He described the numerous common symptoms of chronic sinusitis, as well as the key factors that should be noted in the patient history. Evidence-based recommendations of the American Academy of Otolaryngology—Head and Neck Surgery (AAOHNS) state that the presence of two or more signs or symptoms persisting beyond 12 weeks is highly sensitive for diagnosing chronic sinusitis, and that inflammation must be documented in addition to persistent symptoms. Dr. Dorsen also discussed the critical components of physical examination, which should a complete head and neck examination to confirm the diagnosis of chronic sinusitis and to rule out more serious disorders.

FESS is the current gold standard for the treatment of inflammatory sinus disorders. While balloon sinuplasty was originally envisioned as a less invasive alternative to FESS, the stand-alone use of the procedure remains controversial, as some practitioners feel that it does not address underlying issues of sinusitis. Currently, there are no randomized studies that compare balloon sinuplasty with FESS. Dr. Dorsen noted, however, that there are some existing data suggesting that balloon sinuplasty, either alone or in combination with conventional surgical treatment, is a viable option for sinus surgery in patients with chronic sinusitis unresponsive to medical management.

The American Rhinologic Society (ARS) position statement regarding balloon sinuplasty, which is endorsed by the AAOHNS, states that it is an appropriate therapeutic option for selected patients with sinusitis. Many health plans cover stand-alone use of balloon sinuplasty to treat chronic sinusitis as long as very specific criteria are met. Generally, patients must be 18 years of age or older with the presence of two ore more signs or symptoms of chronic sinusitis persisting for more than 12 weeks, with documented inflammation, as well as failure of appropriate medical treatment.

In his closing thoughts, Dr. Dorsen stated that, “Although FESS remains the gold standard for surgical treatment of inflammatory sinus disorders, balloon sinuplasty may gain more widespread acceptance and eventually become accepted as a standard of care as more randomized studies are conducted and longer-term data become available.” By providing unbiased evaluation of medical need for surgery in patients with chronic sinusitis, external independent medical review facilitates effective care, which is often complicated by continually evolving technologies and treatment guidelines. Independent medical review also provides ready access to specialists, which healthcare plans may lack internally, allowing for timely determination of whether the requested treatment falls under medical necessity guidelines and the latest standard of care.

About AllMed
AllMed Healthcare Management provides physician review outsourcing solutions to leading health plans, medical management organizations, TPAs and integrated health systems, nationwide. AllMed offers MedReview(sm), MedCert(sm), and MedDirector(sm) staffing services that cover initial pre-authorizations and both internal and external appeals, drawing on a panel of over 400 board-certified specialists in all areas of medicine. Services are deployed through PeerPoint(R), AllMed's state-of-the-art medical review portal. For more information on how AllMed can help your organization improve the quality and integrity of healthcare, contact us today at info(at)allmedmd(dot)com, or visit us at http://www.allmedmd.com

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Kiki Grant
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