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

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for components of the requested nasal/sinus endoscopy surgical procedure, nasal/sinus endoscopy, surgical, with right maxillary antrostomy and nasal/sinus endoscopy, surgical, with ethmoidectomy, partial (anterior).The requested services of a right maxillary antrostomy and anterior ethmoidectomy are medically necessary based on the submitted record. Both of the requested procedures are a component of functional endoscopic sinus surgery (FESS). FESS is typically performed for either recurrent acute (RARS) or chronic rhinosinusitis (CRS). It should only be recommended to patients who meet the strict diagnostic criteria for rhinosinusitis and who are refractory to maximal medical management such as intranasal saline, topical steroids, and antibiotics.

Nature of Statutory Criteria/Case Summary: The patient is a 55-year-old female who has been diagnosed with a deviated nasal septum due to assault on 7/8/22. Since the injury, the patient has developed a saddle nose deformity, nasal obstruction, septal deviation, and external valve collapse. The treating physician plans to reconstruct her nose with cartilage graft. The Health Plan indicates that the requested treatment is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. At issue is whether rhinoplasty, secondary; major revision (nasal tip work and osteotomies) (CPT 30450), and graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) (CPT 21235) is medically necessary for the treatment of this patient’s medication condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral nasal and sinus surgery. While sinus surgery may be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, in this case, the patient does not meet the criteria for the requested service. The American Academy of Otolaryngology – Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12-week consecutive duration.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a rhinoplasty primary with major septal repair. This patient has a history of long-standing allergic rhinitis for over 20 years. There is a lack of report or documentation of failure of recent, medically supervised conservative nasal therapy. Physical examination shows only mild tip ptosis and mild septal deviation. The statement by the provider that operative treatment of mild deformity would have an outsized or marked effect in the presence of intranasal swelling is unsupported by peer-reviewed medical literature. Overall, there is a lack of support for the use of the requested procedure in the peer-reviewed medical literature.

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 septum was denied, the published record says the denial is worth fighting.