Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Obstruction

Treatment: CPT code 30465 (repair of nasal vestibular stenosis (e.g. spreader grafting, lateral nasal wall reconstruction) and CPT code 20912 (cartilage graft; nasal septum)

The insurer denied coverage for CPT code 30465 (repair of nasal vestibular stenosis (e.g. spreader grafting, lateral nasal wall reconstruction) and CPT code 20912 (cartilage graft; nasal septum)

The denial is overturned.

The patient is a female with a history of significant nasal obstruction attributed to a deviated nasal septum and nasal valve collapse who has been followed by an Ear Nose & Throat specialist and failed routine nasal treatments with use of nasal sprays and medications including steroids. She noted functional limitations with difficulty performing routine activities of daily living including exertional activities such as exercise and near complete nasal obstruction with occasional obligate mouth breathing as a result. She did endorse daily fatigue and symptoms such as headaches when her symptoms were at their worst. She was evaluated and noted to have a deviated nasal septum, narrow nasal airways bilaterally and evidence of nasal valve collapse from both her valve region and as a result of tip ptosis and lack of support. 

Nasal reconstruction was recommended with repair of her deviated nasal septum, reconstruction of her collapsed nasal valves with cartilage grafting including support of her nasal tip ptosis and airway compromise. She underwent an uncomplicated nasal reconstruction and has continued to see breathing improvement at subsequent follow up visits with improvement in her quality of life as it related to her nasal obstruction.

This patient had nasal collapse with internal and external valve obstruction. Spreader grafts were necessary to open the internal and external nasal valves. Her obstruction is anatomic rather than allergic, and nasal sprays will not improve her symptoms. The spreader grafts will improve function. Collapse of the internal nasal valves is a well-recognized source of nasal obstruction. 

According to Grabb and Smith's Textbook of Plastic Surgery (8th Edition 2019), "The internal nasal valve is the angle formed by the junction of the nasal septum and the caudal margin of the upper lateral cartilage, and is usually 10 to 15 degrees. It can be responsible for up to 50% of the total airway resistance, and is the narrowest segment of the nasal airway. Occasionally, the head (anterior-most portion) of the inferior turbinate can be hypertrophied enough to cause further diminishment of the cross-sectional area of this region. Traditionally, a positive Cottle sign (lateral traction on the cheek leading to increased airflow) signals collapse of the internal nasal valve and indicates the need for spreader grafts to increase the valve angle and stent the airway open." 

This patient had a positive Cottle sign and collapse of the internal and external valves. Spreader grafts are never used in cosmetic procedures. The placement of spreader grafts will widen the nose, which is not a desired goal in aesthetic rhinoplasty. The indication for spreader grafts is functional internal and external valve obstruction as was experienced by this patient.  Her nasal breathing has improved after surgery, consistent with the anatomic origin of her nasal obstruction.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The procedure was medically necessary and in the best interested of the patient to improve her nasal airway. Alar spreader grafts and associated cartilage grafting were medically necessary for this patient.

The insurer's denial of coverage for CPT code 30465 (repair of nasal vestibular stenosis (e.g. spreader grafting, lateral nasal wall reconstruction) and CPT code 20912 (cartilage graft; nasal septum) is reversed. Medical necessity is substantiated.