Rhinoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for facial feminization surgeries (CPT code 30420 (rhinoplasty, primary); CPT code 14041 (adjacent tissue transfer); CPT code 21209 (osteoplasty); CPT code 21139 (reduction forehead); CPT code 40799 (lip surgery procedure); CPT code 21122 (genioplasty, sliding osteotomy, two or more). Findings: The physician reviewer found that a portion of the requested services is medically necessary and reconstructive in nature. Specially, CPT code 21139 (reduction forehead) and CPT code 14041 (adjacent tissue transfer) are medically necessary for the treatment of this patient’s gender dysphoria and is reconstructive in nature. The medical literature supports that facial feminization surgery can help to approximate a feminine appearance.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rhinoplasty with the approved septoplasty. The records provided for review document that this patient has a symptomatic deviated nasal septum as a result of trauma, and correction of the deviated nasal septum has been authorized. In addition, the patient has a bump on his nose that is secondary to the same trauma. The records do not document any deviation of the nasal bones or breathing obstruction medically attributable to the bump on the nose. Thus, correction of the nasal bump would not be to improve a functional deficit. Spataro and Most noted that, “physical examination findings are subjective and prone to bias.

Where the denial was upheld

Standard Review A transgender female enrollee has requested authorization and coverage for facial feminization surgeries (craniofacial coronal reconstruction with hydroxyapatite (HA) cement, osteoplasty of facial bone reduction of mandibular angles, rhinoplasty major, neck liposuction, upper lip shortening and lowering of the hairline). The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for the treatment of the enrollee’s gender dysphoria. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

The patient is a 51-year-old female who had chronic breathing problems due to a nasal septal deviation. She underwent septoplasty in August 2005, which was done entirely through an internal nasal incision. Following surgery, her provider noted “nasal breathing good. Also interested in cosmetic nasal tip surgery.” The patient was advised to wait at least six months prior to any rhinoplasty. The patient now contends there is a nose “bump” located on the right side of her nose that was not present prior to surgery. She would like this “bump” surgically corrected.

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