Home / Conditions / Nasal Air Obstruct
Nasal Air Obstruct: when insurers say no, reviewers often say yes
In 33 published external-review decisions involving nasal air obstruct, independent physician reviewers overturned the insurer’s denial 42.4% of the time.
Published decisions
33
2001–2026
Overturned
42.4%
14 denials reversed
Most-fought treatments for nasal air obstruct
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Sinus Surgery | 9 | 44.4% |
| Septoplasty | 6 | 50% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 23 | 52.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 20% |
Typical time to a decision
21 days
Most land between 15 and 21 days
Handled as urgent
12.1%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repair of the vestibular stenosis to be performed along with a septoplasty and turbinate reduction. The requested treatment for this patient is the repair of nasal valve collapse (NVC), specifically to be performed concurrently with nasal septoplasty and bilateral inferior turbinate reduction. NVC results from structural incompetence of the external and/or internal nasal valve, which leads to dynamic obstruction of the nasal vestibule during inspiration. One systematic review and meta-analysis found that their results support the effectiveness of nasal valve surgery in treating NVC. A prospective nonrandomized study evaluated the use of bioabsorbable implants for the correction of NVC.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rhinoplasty for treatment of the enrollee’s nasal injury.Findings: The physician reviewer found that based on the patient’s complaints and review of the photographs, rhinoplasty consisting of external nasal bony work is supported as medically necessary for treatment of this patient’s nasal fracture and reconstructive in nature. The patient presents with an abnormal condition as the result of nasal trauma. The patient has nasal deformity and nasal airway obstruction as a direct result of the previous nasal fracture. As noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is “performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for nasal valve repair with subcutaneous/submucosal lateral wall implant(s). Nasal valve collapse (NVC) refers to either dynamic or static narrowing of the nostrils and leads to a sensation of impeded nasal airflow. As NVC is an anatomic obstruction, medical therapy, such as topical medicated nasal sprays, does not play a significant role in its management. The standard management for NVC includes surgical placement of a cartilage graft in the area of narrowing or weakness. Two randomized controlled clinical trials in 2018 and 2019, respectively, established the safety and efficacy of absorbable nasal implants (ANIs) for the treatment of patients with lateral nasal wall (LNW) insufficiency and patients with dynamic NVC.
Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the balloon sinus ostial dilation for treatment of the enrollee’s nasal obstruction and chronic sinusitis. Findings: The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. This patient reportedly had symptoms of recurrent acute rhinosinusitis with multiple episodes that was partially controlled with medications, but the symptoms recurred. The physical examination and CT imaging confirmed evidence of nasal septal deviation and mucous membrane thickening within the maxillary sinus with presence of a sinus cyst.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
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 nasal air obstruct was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.