Septoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A 67-year-old female enrollee has requested authorization and coverage for functional endoscopic sinus surgery and septoplasty.. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s deviated nasal septum; nasal turbinate hypertrophy; chronic sinus infection; chronic sinusitis; and nasal polyps.At issue in this case is whether the requested functional endoscopic sinus surgery and septoplasty are medically necessary for treatment of the patient’s medical condition.Per researchers, nasal polyps cause nasal obstruction, discharge and reduction in or loss of sense of smell, but their etiology is unknown.

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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral nasal and sinus surgery. While sinus surgery may be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, in this case, the patient does not meet the criteria for the requested service. 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.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nasal/sinus endoscopy along with the approved submucous resection inferior turbinate, partial or complete, any method and septoplasty or submucous resection, with or without cartilage scouring, contouring or replacement with graft. Findings: The physician reviewer found that while chronic rhinosinusitis is often successfully managed in the primary care setting using antibiotics, topical or oral steroids, and saline nasal irrigation, surgery is an option when medical management fails. In this case, the patient has a history of allergies and sinus infections, but the records do not reflect chronic sinusitis, which is defined as twelve consecutive weeks of symptoms, or recurrent acute sinusitis, requiring four or more provider visits in a year.

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