Ear, nose and throat procedures: 76% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2026 · Medical necessity · age 21–30 Sinus surgery · Ear, nose and throat The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus, bilateral balloon ostial dilation of the frontal and sphenoid sinuses, and bilateral turbinate reduction. The…

   The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus, bilateral balloon ostial dilation of the frontal and sphenoid sinuses, and bilateral turbinate reduction. The patient meets the clinical criteria for chronic rhinosinusitis involving the bilateral maxillary, frontal, and sphenoid sinuses. The record also establishes a diagnosis of bilateral inferior turbinate hypertrophy (ITH). The patient’s sinus disease and ITH have been recalcitrant to maximal medical therapy. This information supports the use of both balloon dilation of the sinuses and bilateral turbinate reduction (ITR) in this clinical setting. As such, the requested procedures — bilateral balloon ostial dilation of the maxillary sinus, bilateral balloon ostial dilation of the frontal and sphenoid sinuses, and bilateral turbinate reduction (CPT codes 31295‑50, 31298‑50, 30140‑50) — are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN26-46606

2. Overturned 2025 · Medical necessity · age 65+ Sinus surgery · Ear, nose and throat The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses. Balloon sinus ostial dilation is…

   The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses. Balloon sinus ostial dilation is typically performed for patients who present with either recurrent acute (RARS) or chronic rhinosinusitis (CRS). It should only be recommended to patients that meet the strict diagnostic criteria for rhinosinusitis and who are refractory to maximal medical management. Patients can be diagnosed with CRS if they have symptoms such as nasal congestion and nasal discharge for at least 12 consecutive weeks, and have correlative objective findings of sinusitis on computed tomography (CT) and/or nasal endoscopy. A study reports that the use of balloon dilation demonstrated statistically significant improvement in patients with rhinosinusitis. Based on the provided documentation, this patient meets the clinical criteria for CRS, which has been affecting the bilateral maxillary, frontal, and sphenoid sinuses. The patient’s sinus disease has also been recalcitrant to maximal medical therapy. Overall, the medical literature and guidelines support the use of balloon sinus ostial dilation for this patient’s condition. Given these findings, the requested bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient’s 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.

   Case MN25-46365

3. Overturned 2025 · Medical necessity · age 51–64 Sinus surgery · Ear, nose and throat The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses. Balloon ostial dilation of the sinuses…

   The physician reviewer found that a patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses. Balloon ostial dilation of the sinuses is typically performed on patients with either recurrent acute rhinosinusitis or chronic rhinosinusitis (CRS). It should only be recommended to patients who meet the strict diagnostic criteria for rhinosinusitis and who are refractory to maximal medical management. Patients can be diagnosed with CRS if they have symptoms such as nasal obstruction/congestion, nasal discharge, and/or facial pressure/pain for at least 12 consecutive weeks, and correlative objective findings of sinusitis on computed tomography (CT) and/or nasal endoscopy. In one study, the use of balloon dilation demonstrated statistically significant improvement in patients with CRS. Based on the records, this patient meets the clinical criteria for CRS, which is affecting the bilateral maxillary, frontal and sphenoid sinuses. The patient’s sinus disease has also been recalcitrant to appropriate medical therapy. The medical literature supports the use of balloon ostial dilation in this patient’s clinical setting. Therefore, the requested bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-46335

4. Overturned 2025 · Medical necessity · age 51–64 Other · Brain and nerves The physician reviewer found that a patient has requested authorization and coverage for open implantation of a hypoglossal nerve neurostimulator.The records document that this patient presents with a history of moderate obstructive sleep apnea (OSA) and body…

   The physician reviewer found that a patient has requested authorization and coverage for open implantation of a hypoglossal nerve neurostimulator.The records document that this patient presents with a history of moderate obstructive sleep apnea (OSA) and body madd index within the required range. The provider reported that the patient has failed to tolerate or derive consistent benefit from positive airway pressure (PAP) therapy, despite appropriate attempts at use. The patient underwent a thorough examination, and no anatomical or endoscopic features were identified that would contraindicate treatment with hypoglossal nerve stimulation. Overall, the patient meets the U.S. Food and Drug Administration (FDA) requirements as an adult patient with moderate to severe OSA, PAP intolerance/failure, and a BMI less than 40 kg/m2. Hypoglossal nerve neurostimulator implantation is an evidence-supported alternative therapy to reduce OSA severity and improve symptoms and quality of life when PAP is not a viable option. One study found that hypoglossal nerve stimulation is a “safe and effective treatment for patients with OSA, exhibiting high adherence and satisfaction rates.” Another study reported that hypoglossal nerve stimulation “significantly improves quality of life in patients with OSA and reliably produces clinically meaningful effects on daytime sleepiness, daytime functioning, and sleep quality.” Given this support, the requested open implantation of a hypoglossal nerve neurostimulator is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in neurology with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s 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.

   Case MN25-46297

5. Overturned 2025 · Medical necessity · age 41–50 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for balloon ostial dilation of the bilateral maxillary sinuses and balloon ostial dilation of the bilateral frontal and sphenoid…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for balloon ostial dilation of the bilateral maxillary sinuses and balloon ostial dilation of the bilateral frontal and sphenoid sinuses. Balloon sinus dilation is typically performed for either recurrent acute rhinosinusitis or chronic rhinosinusitis. Balloon sinus dilation offers a significant benefit over traditional functional endoscopic sinus surgery as it carries less morbidity and can frequently be accomplished in an office setting. Balloon sinus dilation should only be recommended to patients who meet the strict diagnostic criteria for rhinosinusitis and who are refractory to maximal medical management. Patients can be diagnosed with chronic rhinosinusitis if they have symptoms such as nasal congestion and nasal discharge for at least 12 consecutive weeks and have correlative objective findings of sinusitis on computed tomography scan and/or nasal endoscopy. Numerous randomized controlled trials have been performed, establishing the safety and efficacy of balloon sinus dilation. Based on the provided documentation, this patient meets the clinical criteria for chronic rhinosinusitis, which is affecting the bilateral maxillary, frontal, and sphenoid sinuses. The above data support the use of balloon ostial dilation in these cases. Therefore, the requested balloon ostial dilation of the bilateral maxillary sinuses and balloon ostial dilation of the bilateral frontal and sphenoid sinuses are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-46270

6. Overturned 2025 · Medical necessity · age 31–40 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses. Balloon sinus dilation is typically performed for either recurrent acute rhinosinusitis or chronic rhinosinusitis. Balloon sinus dilation offers a significant benefit over traditional functional endoscopic sinus surgery as it carries less morbidity and can frequently be accomplished in an office setting. Balloon sinus dilation should only be recommended to patients who meet the strict diagnostic criteria for rhinosinusitis and who are refractory to maximal medical management. Patients can be diagnosed with chronic rhinosinusitis if they have symptoms such as nasal congestion and nasal discharge for at least 12 consecutive weeks and have correlative objective findings of sinusitis on computed tomography scan and/or nasal endoscopy. Numerous randomized controlled trials have been performed, establishing the safety and efficacy of balloon sinus dilation. Based on the provided documentation, this patient meets the clinical criteria for chronic rhinosinusitis, which is affecting the bilateral maxillary, frontal, and sphenoid sinuses. The above data support the use of balloon ostial dilation in these cases. Therefore, the requested bilateral balloon ostial dilation of the maxillary sinus and bilateral balloon ostial dilation of the frontal and sphenoid sinuses are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-46201

7. Upheld 2025 · Medical necessity · age 21–30 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for a procedural intervention for Eustachian tube dysfunction. This procedure is generally considered when patients have persistent…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for a procedural intervention for Eustachian tube dysfunction. This procedure is generally considered when patients have persistent symptoms supported by objective clinical findings after appropriate evaluation. Clinical guidelines emphasize the importance of correlating symptoms with diagnostic testing before proceeding with intervention. In this case, the available documentation does not demonstrate sufficient objective findings to support the diagnosis or need for the requested procedure. Given the lack of clinical evidence supporting its use in this setting, the requested procedure is not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested service is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45571

8. Upheld 2025 · Medical necessity · age 21–30 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for balloon ostial dilation of maxillary sinus, balloon ostial dilation of the frontal and sphenoid sinus – (with the approved…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for balloon ostial dilation of maxillary sinus, balloon ostial dilation of the frontal and sphenoid sinus – (with the approved submucous resection inferior turbinate, partial or complete). Per the medical records, a close review of the submitted computed tomography (CT) images shows narrowed frontal, sphenoid, and maxillary sinus openings that are either patent or are not sufficiently well visualized. In this clinical setting, given that current medical literature does not support balloon sinus dilation for the treatment of unobstructed sinuses, balloon ostial dilation of maxillary sinus, balloon ostial dilation of the frontal and sphenoid sinus – (with the approved submucous resection inferior turbinate, partial or complete) – is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology – head and neck surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-45298

9. Upheld 2025 · Medical necessity · age 21–30 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a balloon ostial dilation procedure performed to the bilateral maxillary sinuses and/or the left frontal sinus. In this case, a…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a balloon ostial dilation procedure performed to the bilateral maxillary sinuses and/or the left frontal sinus. In this case, a review of the medical records suggests that the patient has chronic sinusitis. Specifically, the patient has indicative symptoms of chronic sinusitis, including drainage, congestion, loss of smell, and sinus pressure. The patient’s nasal endoscopy described significant edema and drainage throughout the nasal sinuses. The patient had been previously treated with appropriate medical management. However, on closer inspection, a review of the sinus computed tomography (CT) images provided for review demonstrates no evidence of sinus mucosal thickening, sinus obstruction, or layering of fluid in the sinuses, establishing that the patient has chronic sinusitis. Further, there is no clear documentation that any medical management for the current episode had been attempted. Considering the patient’s normal sinus CT scan on the day the patient presented with symptoms and no clear evidence of treatment for or duration of the current episode, no convincing evidence is provided to support the recommendation for surgical management of the sinuses at this time. As such, the requested balloon ostial dilation procedure performed to the bilateral maxillary sinuses and the left frontal sinus is not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the patient's 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.

   Case MN25-45085

10. Upheld 2025 · Medical necessity · age 51–64 Sinus surgery · Ear, nose and throat The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral nasal balloon ostial dilation. According to the American Academy of Otolaryngology, patients are diagnosed with…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral nasal balloon ostial dilation. According to the American Academy of Otolaryngology, patients are diagnosed with chronic rhinosinusitis if they have two or more symptoms such as nasal obstruction, nasal congestion, nasal discharge, hyposmia, and/or facial pressure or pain for at least 12 consecutive weeks and have correlative objective findings of sinusitis on computed tomography (CT) and/or nasal endoscopy. Recurrent acute rhinosinusitis is diagnosed by four episodes of acute rhinosinusitis in the last 12 months with distinct symptom-free intervals between episodes. The American Academy of Otolaryngology states that balloon sinus dilation is a therapeutic option in the treatment of recurrent acute rhinosinusitis and chronic sinusitis, however there should be corresponding findings on endoscopy and CT prior to moving forward with surgical intervention. Based on the records, and the criteria set forth by the literature, this patient does not meet the diagnostic threshold for either chronic or recurrent acute rhinosinusitis. While the patient has a history of recurrent sinus infections, the reported frequency is only three per year. Additionally, though nasal endoscopy showed narrowing of the ostiomeatal complex, a CT scan did not identify any ostiomeatal obstruction or narrowing or any additional paranasal sinus disease. Given these findings, the requested bilateral nasal balloon ostial dilation is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

    Case MN25-44684

11. Upheld 2025 · Medical necessity · age 31–40 Sinus surgery · Ear, nose and throat Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for sinus surgery, (bilateral balloon ostial dilation of the maxillary sinuses), and the frontal and sphenoid sinuses. The American Academy of Otolaryngology-Head and Neck…

    Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for sinus surgery, (bilateral balloon ostial dilation of the maxillary sinuses), and the frontal and sphenoid sinuses. The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical consensus statement on balloon sinus ostial dilation does not reach a consensus that balloon sinus ostial dilation is appropriate for patients with chronic rhinosinusitis (CRS) without nasal polyps, either as a stand-alone procedure or as an adjunct. In this clinical setting, given the insufficient nature of peer-reviewed evidence to support the use of balloon sinus ostial dilation for the treatment of CRS, the services at issue were not medically indicated. Therefore, sinus surgery, (bilateral balloon ostial dilation of the maxillary sinuses), and the frontal and sphenoid sinuses were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology – head and neck surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

    Case MN25-43932

12. Upheld 2025 · Medical necessity · age 0–10 Tonsillectomy · Brain and nerves The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for immediate scheduling of the approved adenotonsillectomy surgery. While there is currently no clinical consensus or…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for immediate scheduling of the approved adenotonsillectomy surgery. While there is currently no clinical consensus or practice guideline specifically regarding the timing of adenotonsillectomy for children with obstructive sleep apnea (OSA), typical indications for an urgent adenotonsillectomy include age younger than three years, a high apnea-hypopnea index (AHI) that is over the average 39.4/hour, and an oxygen saturation level that is persistently below 80% despite the use of supplemental oxygen. Per the medical records, the patient is seven years old, with a sleep study that demonstrated an AHI of 19.4/hour, an average oxygen saturation level of 96%, and an oxygen nadir of 86%. The records do not indicate that the patient requires supplemental oxygen. In this clinical setting, given this patient’s comparatively reassuring data points from the sleep study, while adenotonsillectomy is certainly indicated and should proceed in as timely a manner as feasible, the requested immediate scheduling of the procedure is not medically indicated. Therefore, the immediate scheduling of the approved adenotonsillectomy surgery is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in otolaryngology – head and neck surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee's 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.

    Case MN25-43929