There is already evidence that the clinical consensus statement may lead to improved health insurance coverage for balloon sinuplasty. Shortly after the statement’s release, Anthem changed their classification of balloon sinus ostial dilation from “investigational” to “medically necessary” for patients who meet the criteria outlined in the consensus statement.
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May 2018Expanded health insurance coverage of balloon dilation is a “win-win-win scenario,” Dr. Bikhazi said. It’s a win for patients, because appropriate candidates can undergo an in-office procedure at a lower cost and with decreased risk of complications. It’s a win for physicians because they can receive reimbursement while treating patients in accordance with best practices; insurers win because patients can be treated in the lowest-cost setting.
Previously, patients who could not afford to pay out of pocket for balloon sinuplasty often opted for insurance-covered sinus surgery. “Having to take them to the operating room when I did not need to is just ridiculous,” Karen Stierman, MD, an otolaryngologist with the ENT & Allergy Center of Austin. “Now that more insurances cover in-office balloon procedures, people who have sinusitis without polyps can be considered for an office-based balloon procedure and avoid general anesthesia.”
According to the consensus statement, however, balloon sinuplasty is not appropriate for the management of sleep apnea or headache in patients who do not otherwise meet the criteria of chronic sinusitis or recurrent acute sinusitis. That news may be disappointing to patients interested in balloon dilation for those indications.
“I have people come to my office and say, ‘Can I have a balloon dilation to fix my breathing? Or to fix my sleep apnea?’ because that’s how it’s being marketed in some places,” Dr. Stierman said.
The lack of inclusion of these indications in the consensus statement “does not say that balloon dilation has no potential value or does not work in individual cases,” for barotrauma and headaches, Dr. Denneny said. Rather, “at this time, this is not a substantial body of scientific evidence that rose to the level of consensus for these other disease processes as it did for chronic rhinosinusitis,” he said.
Balloon dilation of the sinuses is an evolving technology that has been shown to have benefit in a number of circumstances. As with most evolving technologies in the field of medicine, it’s important to have a blueprint to objectively look at things. Everyone’s end goal is to have a very safe, effective treatment for patients. —James C. Denneny, III, MD
Additional Research Is Necessary
The consensus statement will be updated at least every three years to reflect new knowledge. For instance, although otolaryngologists have been using balloon technology to dilate the frontal, maxillary, and ethmoid sinuses for years, the only location-specific outcome statement that reached consensus is, “Balloon dilation can be effective in front sinusitis.” Dr. Bikhazi said that may be because there’s not yet evidence to suggest that balloon dilation is a superior choice for maxillary sinus disease, as compared with sinus surgery. However, based on his experience with the REMODEL study, which showed that stand-alone balloon dilation is as effective as FESS in the treatment for CRS in patients with maxillary sinus disease, Dr. Bikhazi said, “I think maxillary sinus will follow the front sinus recommendation in the future” (Am J Rhinol Allergy. 2014;28:323–329. Laryngoscope. 2016;126:44–50).