Changing insurance coverage for balloon sinuplasty


Until 4 days ago, patients with Anthem-Blue Cross Blue Shield plans were denied coverage for balloon sinus dilation on the grounds that this procedure was "investigational" and therefore "not medically necessary." They held this position for quite some time, despite nearly all other private and government funded payers covering the procedure. I applaud their decision to reverse their policy and am excited now to be able to offer this minimally invasive and effective procedure to our large number of patients with this health plan.

Funny (and sad) how much insurance companies dictate what treatments we can offer our patients. For something like a surgical procedure, you would think that since all insurance companies have access to the same medical studies, their policies and guidelines should be similar.

So on this occasion, sparked by Anthem's recent policy revision, I thought it would be fun to show some similarities and differences between the balloon sinuplasty policies of a few of the big insurance plans.

First, how do they define the diagnosis of chronic sinusitis?

You would think they would agree on what constitutes the diagnosis, right? Well...

1) Anthem-BCBS: symptoms longer than 12 weeks, and any one of the following: "CT findings suggestive of obstruction or infection" or "Nasal endoscopy findings suggestive of significant disease" or "Physical exam findings suggestive of chronic/recurrent disease".

2) Cigna: two or more of these symptoms lasting more than 3 months: nasal obstruction, foul drainage, facial pain/pressure/fullness, decreased sense of smell; and any of the following CT scan findings: mucosal thickening more than 3mm, air fluid levels, opacification, or nasal polyps.

3) United: symptoms longer than 12 weeks, and any of the following CT findings: mucosal thickening, bony remodeling, bony thickening, or obstruction of the ostiomeatal complex.

So if you are an Anthem patient, you can have a completely normal CT scan of the sinuses, as long as there is evidence of "significant disease" on physical exam or nasal endoscopy. For the other 2 companies, it really doesn't matter what you or your nose looks like, as long as certain criteria are met on the CT scan.

Second, what do they mean by "maximal medical management?"

Most insurance companies (rightly so) require patients to fail some sort of medical management before approving surgery. Again, you would think these guidelines would be similar...

1) Anthem-BCBS: all of the following must have been tried: 4 consecutive weeks of antibiotics and inhaled steroid and nasal lavage (saline rinses) and allergy testing (if symptoms consistent with allergic rhinitis).

2) Cigna: all of the following: at least two different "full courses" of antibiotics and steroid nasal spray and antihistamine nasal spray and/or decongestant and nasal saline irrigation

3) United: one or more of the following: nasal lavage, antibiotic therapy if bacterial infection is suspected, nasal steroid spray.

So, if you are an Anthem patient and have suffered through 5 different 10 day courses of antibiotics in the last 6 months, and none of these has helped you...good news! You get to be on 4 more weeks of antibiotics (equally unlikely to work, but sure to cause some serious GI distress!) before you can have a simple in-office surgical procedure. And if you are a United patient, well, as long as you've tried some saline in your nose, you're covered!

Makes it difficult to treat every patient the same, when patients' insurance policies are so different!

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© 2017 by Jonathan C. Mills, MD