Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deviated septum and difficulty with nasal breathing
Treatment: CPT code 30465 vestibular stenosis repair
The insurer denied coverage for CPT code 30465 vestibular stenosis repair.
The denial is overturned. 

This is a female who presented for an office visit with a plastic and general surgeon for evaluation of deviated nasal septum and difficulty breathing. The patient reported difficulty breathing through both nostrils with the right worse than the left. She stated that she snores and has difficulty breathing at night as she only breathes through her mouth. The patient was interested in functional improvement. On examination, the patient was noted with a small dorsal nasal hump on the nasal dorsum with slight deviation of the nasal bones to the right, slight enlargement of the right nasal tip as compared to the left, the nasal passages somewhat patent, deviation of the nasal septum to the right, significantly decreased air flow through the right nostril as compared to the left that improved significantly with the Cottle maneuver bilaterally. The treatment plan included correction of deviated septum with recommended open septoplasty and placement of spreader grafts and out-fracturing of the turbinates to improve nasal airflow. A computed tomography (CT) scan of the facial bones was recommended in order to better delineate the anatomy due to the multiple episodes of trauma. The patient was also advised regarding an unrelated repair of a right split earlobe during this visit. The patient underwent an open septoplasty with placement of bilateral spreader grafts for the pre-operative diagnosis of deviated septum and difficulty with nasal breathing; the post-operative diagnosis was the same. The patient tolerated the procedure well without complications and was taken to the post-operative care unit in stable condition. The insurer has denied coverage for CPT code 30465-vestibular stenosis repair as not medically necessary.

This patient had nasal collapse with internal valve obstruction.  Internal valve collapse is a dynamic examination finding and thus poorly demonstrated on static photographs. The surgeon's preoperative exam showed internal valve collapse that improved dramatically with the Cottle maneuver. Spreader grafts were necessary to open the internal nasal valves. Her obstruction was 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 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 valve obstruction as was experienced by this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The medical necessity for CPT code 30465 vestibular stenosis repair is substantiated. The insurer's denial is overturned.