Nasal Obstruction denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a facial plastic surgeon for the evaluation of the enrollee, who has a deviated septum. Findings: The physician reviewer found that there is sufficient support in the documentation and in the medical literature for the requested services in this clinical setting. The patient has evidence of nasal deformity and nasal obstruction following previous nasal fracture. He has been treated symptomatically for his nasal obstruction, but this was unsuccessful. The referring surgeon documented nasal deformity and nasal obstruction, but his surgical plan only included partial treatment for the nasal obstruction. The patient had external nasal valve collapse that can be contributing to his nasal obstruction, but was not being addressed by this surgeon.

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: An enrollee has requested reimbursement for medical services provided for emergency services that he did not receive. Findings: The physician found that the enrollee has a history of prior nasal surgical interventions. In a previous year, the patient underwent open rhinoplasty and septoplasty along with bilateral inferior turbinate partial resection for symptoms of nasal blockage obstruction and a desire to have improved appearance of the external nose. The patient presented with reports of sinus pressure and recurrent infections. Computed tomography (CT) scan of the sinuses showed evidence of opacification of the right maxillary sinus however there is no evidence of any inflammatory or infective changes of the ethmoid or frontal sinuses.

Nature of Statutory Criteria/Case Summary: An 18-year-old female enrollee has requested authorization and coverage for septoplasty (CPT code 30520), inferior turbinate reduction (CPT code 30140), and open nasal reconstruction (CPT code 30410). Findings: The physician reviewer found that According to the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAOHNSF), indications for septoplasty and turbinate reduction surgery include nasal obstruction secondary to septal deviation, refractory to medical management or for surgical access. Although this patient’s records include documentation of septal deviation, turbinate hypertrophy and nasal obstruction, there is no record that adequate medical management has failed to improve this patient’s symptoms. Thus, the requested surgery is not supported as medically necessary for treatment of this patient’s medical condition.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving nasal obstruction, then check the rights and deadlines that apply to your plan.