Is a CT scan of the maxillofacial area without contrast material medically necessary for a patient with nasal congestion and left-sided nasal drainage who has tried nasal sprays and antibiotics (abx) without significant improvement?

Medical Necessity Determination: CT Maxillofacial Without Contrast

Based on the clinical presentation and ACR Appropriateness Criteria, this CT scan does NOT meet medical necessity criteria and should be denied coverage.

Clinical Assessment

The patient presents with:

• Left-sided nasal drainage and congestion
• Symptom improvement over recent weeks
• Negative physical examination (no polyps, masses, or drainage on scope)
• Trial of nasal sprays and antibiotics without significant improvement
• No documented duration of symptoms ≥12 weeks
• Physician states imaging would be "interesting to see" rather than medically necessary

Why This Does Not Meet Criteria

Fails to Meet Chronic Rhinosinusitis Requirements

The ACR Appropriateness Criteria rate CT paranasal sinuses without contrast as "usually appropriate" (9/9) ONLY for surgical candidates with chronic rhinosinusitis or recurrent acute rhinosinusitis 1. This patient does not qualify because:

• Symptom duration is not documented as ≥12 weeks, which is required for chronic rhinosinusitis diagnosis 1, 2
• Patient is improving spontaneously, not a surgical candidate 1
• No documentation of adequate medical management failure (nasal corticosteroids plus saline irrigation) 2
• No documentation of multiple antibiotic courses with appropriate agents 2

Fails Acute Rhinosinusitis Criteria

For acute uncomplicated rhinosinusitis (<4 weeks), CT imaging is rated only 4/9 ("may be appropriate"), essentially not indicated 1, 3. This patient:

• Has negative endoscopic examination (no polyps, masses, or drainage visible) 1
• Shows clinical improvement without intervention 3
• Has no suspected complications (orbital, intracranial, or invasive fungal disease) 1

No Red Flags Present

CT would be appropriate if any of these were present, but none are documented 1, 2:

• Unilateral polyp or mass on examination
• Suspected orbital complications (periorbital cellulitis, vision changes)
• Suspected intracranial complications (severe headache, neurologic deficits)
• Immunocompromised state with suspected invasive fungal sinusitis
• True recurrent acute rhinosinusitis (≥4 episodes per year)

Evidence-Based Rationale

Diagnostic Accuracy Concerns

• Symptom-based diagnosis alone has only 47% correlation with positive CT findings in patients meeting clinical criteria for chronic rhinosinusitis 4
• Negative nasal endoscopy has 91% sensitivity for ruling out significant sinus disease when combined with clinical assessment 5
• This patient has negative endoscopy, making significant sinus pathology unlikely 5

Appropriate Diagnostic Pathway

The correct clinical approach per ACR guidelines 1, 2:

1. For acute symptoms: Observation and symptomatic treatment (no imaging needed)
2. For chronic symptoms (≥12 weeks): Document failure of appropriate medical therapy first
   • Nasal corticosteroids for adequate duration
   • Saline irrigation
   • At least 2 antibiotic courses if bacterial infection suspected
3. Only then consider CT if patient remains symptomatic and is being evaluated for surgery

Radiation Exposure Consideration

• CT delivers 0.1-1 mSv radiation exposure and must be clinically justified 2
• Ordering CT for "interesting to see" without clear clinical indication exposes patient to unnecessary radiation 2

Common Pitfalls to Avoid

This case exemplifies a classic inappropriate imaging scenario 3:

• Ordering imaging for non-specific symptoms without meeting duration criteria
• Using CT as a diagnostic fishing expedition rather than for surgical planning
• Failing to document adequate medical management before imaging
• 18-82% of asymptomatic individuals have incidental sinus abnormalities on CT, which can lead to misleading findings and unnecessary interventions 3

Recommendation

Deny coverage for CT maxillofacial without contrast. The appropriate management is:

• Continue observation given spontaneous improvement 1, 3
• Optimize medical management if symptoms persist (intranasal corticosteroids, saline irrigation) 2, 6
• Document symptom duration and response to therapy 2, 6
• Consider CT only if: symptoms persist ≥12 weeks despite appropriate medical therapy AND patient is being evaluated as surgical candidate 1, 2

The physician's own documentation ("will let me know if he wishes to proceed") indicates this is elective/optional imaging rather than medically necessary 1, 2.