Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Obstruction
Treatment: Nasal septum and inferior turbinate surgery
The insurer denied nasal septum and inferior turbinate surgery.
The determination is overturned.

This is a patient with a nasal obstruction. The previous medical therapy included nasal steroids. The exam revealed a deviated septum and turbinate hypertrophy. A computed tomography (CT) scan showed a septal spur. A septoplasty and turbinate reduction were carried out and are under review for medical necessity.

The patient has nasal obstruction refractory to medical management with documented deviated septum and turbinate hypertrophy.

Per the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines, septoplasty is indicated when there is "Nasal airway obstruction (unilateral or bilateral) causing any of the following: mouth breathing, snoring, nasal congestion, sleep apnea, unresponsive to medical management." (see AAO - HNS Septoplasty guidelines)

Most septoplasty guidelines, to include the AAO-HNS, would recommend a trial of medical therapy prior to proceeding to a septoplasty. Consideration for a septoplasty is given when there is a noted deviated nasal septum causing symptoms that have not responded to an appropriate and reasonable trial of medical therapy. Furthermore, septoplasty is considered as long as there is no other cause for obstruction such as polyps, tumor, etc ("and the rest"). In the appropriately selected patient who has failed medical therapy, septoplasty is a well-accepted and effective procedure carried out by practicing otolaryngologists. (see AAO-HNS guidelines) There is no standard definition of what constitutes a reasonable and appropriate trial of medical therapy. Most otolaryngologists would advocate for a trial that could include but not limited by the individual or combined therapy of nasal saline rinses, a nasal steroid where results are usually seen in 2-4 weeks, anti-histamines, topical anti-histamines, and/or topical anti-cholinergics. Allergy evaluation and therapy is appropriate in the applicable clinical scenario whereby history there is a strong suggestion for an allergic component. There is no prospective study that determines the optimal amount of time that this trial should be given, but most otolaryngologists would consider a 4-6 week trial appropriate.

Indications for turbinoplasty include turbinate hypertrophy causing chronic nasal obstruction that has failed medical management. [See AAOH-HNS Clinic Indicator where turbinoplasty should be considered when there is "Chronic nasal obstruction due in part to inferior turbinate hypertrophy" and there is "failure of directed medical management with continued nasal symptoms (medications, allergy, and duration of therapy)"]. Turbinoplasty has been shown to be a long term effective treatment strategy for turbinate hypertrophy in patients who have failed medical treatment. Similar to as mentioned above regarding septoplasty, there is no standard definition of what constitutes a reasonable and appropriate trial of medical therapy. Most otolaryngologists would advocate for a trial that could include but not limited by the individual or combined therapy of nasal saline rinses, a nasal steroid where results are usually seen in 4-6 weeks, anti-histamines, topical anti-histamines, and/or topical anti-cholinergics. Allergy evaluation and therapy is appropriate in the applicable clinical scenario where by history there is a strong suggestion for an allergic component. There is no prospective study that determines the optimal amount of time that this trial should be given, but most otolaryngologists would consider a 4-6 week trial appropriate.