Septal Deformity 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: An enrollee has requested authorization and coverage for septoplasty or submucous resection (CPT code 30520) and submucous resection inferior turbinate (CPT code 30140). In the peer-reviewed medical literature, researchers reported that OSA is a “common condition, primarily caused by narrowing of the nasal and pharyngeal airway. Treatment with continuous positive airway pressure (CPAP) is considered the first-line of therapy.” Bilateral submucous resection (CPT code 30140) is a technique to improve the airway and has been beneficial in patients with severe obstruction noted on physical examination.

Where the denial was upheld

A 32-year-old male enrollee has requested emergency functional rhinoseptoplasty and osteotomy and related services provided out of the country for the treatment of his medical condition. Findings: The physician reviewer found that this case involves the issue of whether a prudent layperson in the patient’s circumstances would believe he was experiencing an emergency medical condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patient’s health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a nasal valve support. Based on the available documentation and physical examination findings, this patient does not meet the current criteria for consideration of placement of the requested device. Specifically, there is no documentation provided that shows that the patient’s nasal airway is obstructed or blocked. In addition, the CT scan did not demonstrate any significant deformity of the nasal septum, but rather showed open, clear sinuses. In this clinical case, there is no documentation provided that anatomical issues need to be corrected. For these reasons, the requested nasal valve support is not 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 septal deformity, then check the rights and deadlines that apply to your plan.