Deviated Nasal Septum: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patient’s medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhinoplasty with the approved septoplasty. The records provided for review document that this patient has a symptomatic deviated nasal septum as a result of trauma, and correction of the deviated nasal septum has been authorized. In addition, the patient has a bump on his nose that is secondary to the same trauma. The records do not document any deviation of the nasal bones or breathing obstruction medically attributable to the bump on the nose. Thus, correction of the nasal bump would not be to improve a functional deficit. Spataro and Most noted that, “physical examination findings are subjective and prone to bias.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for septorhinoplasty for a deviated nasal septum, causing complaints of breathing problems; allergic rhinitis, and an undesirable cosmetic appearance. She has enlarged inferior turbinates, a small dorsal hump and mild deviation of the dorsum. A progress note from a head and neck plastic surgeon stated a septoplasty and inferior turbinate reduction is a reasonable option for resolving the enrollee’s breathing issues. The surgeon advised a nose-straightening procedure would be a very complex surgery; he could not completely or perfectly straighten her nose. The enrollee also desired dorsal hump reduction. The record indicates the enrollee’s septum is deviated to the left. However, there is insufficient evidence in the record in regard to diminished nasal airflow, breathing difficulties.

A 50-year-old male requested authorization and coverage of a septoplasty for the treatment of deviated nasal septum. The health plan denied the enrollee’s request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plan’s denial on the basis that the requested septoplasty is not medically necessary.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for deviated nasal septum was denied, the published record says the denial is worth fighting.