Should a patient with a history of chronic medical condition, who has undergone previous treatments and requires a specific treatment procedure prior to surgery, be referred to a specialty clinic for further evaluation and treatment, considering their inability to have alternative treatment for healing and complex medical history?

Specialty Referral Authorization: Critical Missing Documentation

This patient cannot be authorized for specialty clinic referral or treatment procedure until mandatory diagnostic imaging is obtained. The request lacks the single most critical requirement for surgical planning and authorization.

Non-Negotiable Requirement: CT Imaging Must Be Obtained First

Before any surgical authorization can be granted, a fine-cut CT scan of the paranasal sinuses must be obtained to confirm the presence and extent of sinus disease, identify anatomic variations, and determine the appropriate surgical approach 1. The American Academy of Otolaryngology strongly recommends that computed tomography with a fine-cut protocol is a non-negotiable requirement before proceeding with functional endoscopic sinus surgery 1.

Why CT Is Mandatory

• The absence of CT imaging makes it impossible to determine the extent of disease, identify anatomic variations, or plan which specific sinuses require surgical intervention 1
• CT is considered mandatory for the safe performance of functional endoscopic sinus surgery, particularly when the ostiomeatal complex and ethmoids are involved 1
• Standard radiographs are inadequate for surgical planning and cannot substitute for CT imaging 1
• Do not proceed with surgery based on symptoms alone without CT confirmation, even with classic symptoms and failed medical therapy 1

Patient Does Meet Clinical Criteria (Pending CT Confirmation)

The patient appears to meet the clinical prerequisites for surgical candidacy based on the available information:

• Chronic symptoms present for adequate duration with documented failed medical management 1
• Multiple appropriate medical therapy trials have been completed, as evidenced by previous treatment history 1
• The 2025 guidelines specifically state that surgeons should not require a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite 1

Required Next Steps Before Authorization

1. Order CT Scan Immediately

The referring provider must order a fine-cut CT scan of the paranasal sinuses before resubmitting this authorization request 1. This imaging will:

• Confirm the presence and extent of sinus disease 1
• Identify any complications such as bony erosion, osteitis, or fungal disease that would require more extensive surgical intervention 1
• Determine whether full functional endoscopic sinus surgery or alternative procedures are appropriate 1

2. Documentation Required After CT Obtained

Once the CT scan is completed, resubmit the authorization with 1:

• CT scan report confirming chronic rhinosinusitis with specific sinuses involved
• Documentation that anticipated benefits of surgery exceed nonsurgical management alone
• Patient counseling regarding realistic expectations, potential for chronicity or relapse, and likelihood of long-term medical management post-surgery
• Specific surgical plan based on CT findings, including which sinuses will be addressed and why

Surgical Planning Considerations (Once CT Available)

The CT findings will determine the appropriate procedure 1:

• If CT shows polyps, osteitis, or extensive disease: Full functional endoscopic sinus surgery would be indicated rather than balloon sinuplasty alone
• If CT shows isolated ostial obstruction without polyps: Balloon sinuplasty could be appropriate

Referral to Specialty Clinic Is Appropriate

Referral to a specialty clinic for complex medical conditions requiring specialized procedures is supported by multiple guidelines when patients have failed conservative management and require interventions beyond primary care capabilities 2.

When Specialist Referral Is Indicated

• Patients who continue to deteriorate clinically despite extended courses of medical therapy should be referred to a specialist 2
• Complex medical conditions requiring specialized expertise warrant referral to ensure optimal safety and benefit outcomes 2
• Patients with persistent bothersome symptoms after basic management should receive specialist treatment 2

Quality Considerations for Specialty Referrals

• Strong consideration should be given to referral of patients who are candidates for specialized procedures to established high-volume centers which can perform these procedures with optimal safety and benefit outcomes 2
• Referring providers should ensure that specialists have appropriate expertise and outcomes data for the proposed procedure 2
• Communication between referring provider and specialist promotes higher quality patient care 2

Critical Pitfalls to Avoid

Do Not Authorize Without CT

• Never approve surgical authorization based on clinical symptoms alone, regardless of how compelling the history or how many medical therapies have failed 1
• Do not assume the extent of surgery based solely on the diagnosis without imaging confirmation of which sinuses are involved 1

Do Not Deny Based on "More Medical Therapy Could Be Tried"

• Do not deny surgery simply because more medical therapy could theoretically be tried when the patient has documented prolonged symptoms with multiple appropriate medical interventions 1
• The patient has clearly exhausted reasonable medical options based on the history provided 1

Ensure Appropriate Specialist Selection

• Referring providers should consider the specialist's clinical expertise, outcomes, and experience with the specific procedure when making referrals 3
• Objective measures of quality should inform the choice of specialist rather than relying solely on subjective factors 3

Recommendation for This Case

Deny the current authorization request with specific instructions to obtain CT imaging first. Once the CT scan is completed and the required documentation is submitted, the authorization can be reconsidered based on imaging findings and appropriate surgical planning 1.

The patient should be informed that:

• CT imaging is a standard, necessary step before any sinus surgery can be safely performed 1
• The imaging will help ensure the correct procedure is performed on the correct sinuses 1
• Authorization will be expedited once imaging and complete documentation are submitted 1