Septal Deviation denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

An enrollee has requested authorization and coverage for rhinoplasty which includes septoplasty procedures (CPT 30420 and CPT 30520).Rhinoplasty is a surgical procedure to smooth out the nasal deformities and to fix nasal breathing problems. Improving nasal valve angle has been shown to improve nasal breathing. In this case, the patient was involved in a motor vehicle accident that resulted in suffering nasal obstruction. The submitted records document that the patient has a septal deviation, and the submitted photographs of the patient demonstrate valve collapse with inspiration. The submitted records reflect that a Cottle maneuver improved the patient’s nasal breathing, thereby indicating nasal valve collapse. Under these circumstances, a septoplasty will be necessary to correct the septal deviation that was also caused by the accident.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the functional endoscopic sinus surgery (FESS) for treatment of the enrollee’s chronic pansinusitis, septal deviation, bilateral nasal valve collapse, bilateral inferior turbinate hypertrophy and dysphagia. Findings: The physician reviewer found that the FESS provided was not medically necessary for treatment of the patient’s medical condition. While sinus ostial dilation can be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, the criteria have not been met in this patient. 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.

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.

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 deviation, then check the rights and deadlines that apply to your plan.