Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consultation with a facial plastic surgeon for the evaluation of the enrollee, who has a deviated septum. Findings: The physician reviewer found that there is sufficient support in the documentation and in the medical literature for the requested services in this clinical setting. The patient has evidence of nasal deformity and nasal obstruction following previous nasal fracture.  He has been treated symptomatically for his nasal obstruction, but this was unsuccessful. The referring surgeon documented nasal deformity and nasal obstruction, but his surgical plan only included partial treatment for the nasal obstruction. The patient had external nasal valve collapse that can be contributing to his nasal obstruction, but was not being addressed by this surgeon. There is different treatment for internal nasal valve issues and external nasal valve issues.  Instead, the referring surgeon made a referral to a facial plastic surgeon.  Consideration of treatment of the external anatomy should not be automatically attributed to cosmetic concerns. Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. The records support that this patient is noted to have an abnormal external deformity (external anatomy) as the result of previous nasal fracture.  Attempts to correct this, should be considered an attempt to approximate a more normal appearance. Thus, treatment of the external anatomy can be considered reconstructive surgery and not necessarily solely cosmetic surgery. The American Society of Plastic Surgeons (ASPS) noted, Reconstructive rhinoplasty transforms nasal abnormalities or damaged nasal structures to a more normal state. Nasal surgery is considered reconstructive surgery and medically necessary to improve nasal respiratory function, treat anatomic abnormalities caused by birth defects or disease and revise structural deformities resulting from trauma. A review by Howard and colleagues stated the following, The rhinoplasty surgeons understanding of the anatomy and physiology of the nasal airway, along with the causes of obstruction, can pave the way for a proper evaluation and appropriate management of nasal airway problems. In this patients case, he has evidence of abnormal nasal appearance and nasal obstruction due to his previous nasal fracture. The referring surgeon was only going to address the nasal obstruction partially with septoplasty and internal nasal valve repair.  The external nasal anatomy, including the external nasal valve and nasal deformity, requires  further evaluation by a facial plastic surgeon.  For these reasons, consultation with a fascial plastic surgeon is medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in  plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees 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.