What is the name of your state? New York
I'm about to file a second-level appeal and I just want to make sure that the following letter made sense.
Dear Board Members:
This appeal qualifies for an expedited appeal. Delay in [HMO] benefit determination, subject to the standard appeal time frames, could jeopardize my ability to regain maximum function of my sinuses. Additionally, I have attached my physician’s letter stating that the standard appeal time will subject me to severe pain that cannot be adequately managed without the treatment that is the subject of this appeal.
In a letter dated 10.29.2006, [HMO] Senior Coordinator, [YYY] wrote that the [HMO] Medical Director “...determined that the requested procedure will not be covered for the following reason(s): “frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254.....” After a first-level appeal was filed on 09.29.06, in a letter dated 10.06.06, [HMO] Senior Coordinator, [ZZZ] wrote that the [HMO] Medical Director “....Based upon the review of all available information and the terms of your plan, our medical director has decided to uphold the initial adverse determination because the frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254. Therefore, medical necessity has not been demonstrated and services are not certified.....” The [HMO] Medical Directors’ determinations are not valid. “A diagnosis of sinusitis,” which has been clinically determined by my doctors, is required. Both [HMO] Medical Directors agreed that I have sinusitis, demonstrated by their approval of CPT code 31254 “Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).” A diagnosis of sinusitis specific to all individual sinuses, as both the [HMO] Medical Directors’ site, is NOT part of [HMO] guidelines.
The [HMO] guidelines, that are attached, state that endoscopic nasal surgery will be covered if the following clinical guidelines are matched.
• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis OR
• CT scan with the findings of severe nasal polyposis
I have met all three required guidelines, for nasal endoscopic surgery. On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis, for more than 3 months. In addition to my doctors notes, I have attached my MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06.
The [HMO] surgical guidelines state that ethmoidectomy, maxillary entrostomy, frontalsinusotomy and sphenoid sinusotomy will be covered if the following clinical guidelines are met:
• Treatment for sinusitis and/or respiratory symptoms should have been rendered within the past year AND
• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• An acute respiratory infection unresponsive to initial antibiotic therapy of 24-48 hours OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis
I have met all four required guidelines, for ethmoidectomy, maxillary entrostomy, frontal sinusotomy and sphenoid sinusotomy . On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis greater than 3 months. In addition to my doctors notes, I have attached MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06. Furthermore, a request was made to approve CPT code 31255. As mentioned above, both OXHP medical directors determined that “The request was denied because limited ethmoidectomy is covered under CPT code 31254.” Without explanation, both medical directors, chose to ignore my doctor’s request, [HMO] guidelines and approved a partial ethmoidectomy, in lieu of a full ethmoidectomy.
Again, demand is made for [HMO] to adhere to its contractual agreement and approve the requested CPT codes 31240, 31255, 31256, 31276. It is cruel for [HMO] to willingly deny and delay coverage that they agreed to, I am entitled to and I paid for, while I suffer unnecessary pain and subject my sinuses to further damage.What is the name of your state?
I'm about to file a second-level appeal and I just want to make sure that the following letter made sense.
Dear Board Members:
This appeal qualifies for an expedited appeal. Delay in [HMO] benefit determination, subject to the standard appeal time frames, could jeopardize my ability to regain maximum function of my sinuses. Additionally, I have attached my physician’s letter stating that the standard appeal time will subject me to severe pain that cannot be adequately managed without the treatment that is the subject of this appeal.
In a letter dated 10.29.2006, [HMO] Senior Coordinator, [YYY] wrote that the [HMO] Medical Director “...determined that the requested procedure will not be covered for the following reason(s): “frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254.....” After a first-level appeal was filed on 09.29.06, in a letter dated 10.06.06, [HMO] Senior Coordinator, [ZZZ] wrote that the [HMO] Medical Director “....Based upon the review of all available information and the terms of your plan, our medical director has decided to uphold the initial adverse determination because the frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254. Therefore, medical necessity has not been demonstrated and services are not certified.....” The [HMO] Medical Directors’ determinations are not valid. “A diagnosis of sinusitis,” which has been clinically determined by my doctors, is required. Both [HMO] Medical Directors agreed that I have sinusitis, demonstrated by their approval of CPT code 31254 “Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).” A diagnosis of sinusitis specific to all individual sinuses, as both the [HMO] Medical Directors’ site, is NOT part of [HMO] guidelines.
The [HMO] guidelines, that are attached, state that endoscopic nasal surgery will be covered if the following clinical guidelines are matched.
• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis OR
• CT scan with the findings of severe nasal polyposis
I have met all three required guidelines, for nasal endoscopic surgery. On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis, for more than 3 months. In addition to my doctors notes, I have attached my MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06.
The [HMO] surgical guidelines state that ethmoidectomy, maxillary entrostomy, frontalsinusotomy and sphenoid sinusotomy will be covered if the following clinical guidelines are met:
• Treatment for sinusitis and/or respiratory symptoms should have been rendered within the past year AND
• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• An acute respiratory infection unresponsive to initial antibiotic therapy of 24-48 hours OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis
I have met all four required guidelines, for ethmoidectomy, maxillary entrostomy, frontal sinusotomy and sphenoid sinusotomy . On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis greater than 3 months. In addition to my doctors notes, I have attached MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06. Furthermore, a request was made to approve CPT code 31255. As mentioned above, both OXHP medical directors determined that “The request was denied because limited ethmoidectomy is covered under CPT code 31254.” Without explanation, both medical directors, chose to ignore my doctor’s request, [HMO] guidelines and approved a partial ethmoidectomy, in lieu of a full ethmoidectomy.
Again, demand is made for [HMO] to adhere to its contractual agreement and approve the requested CPT codes 31240, 31255, 31256, 31276. It is cruel for [HMO] to willingly deny and delay coverage that they agreed to, I am entitled to and I paid for, while I suffer unnecessary pain and subject my sinuses to further damage.What is the name of your state?