Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertrophied inferior turbinate (IT).
Treatment: Septoplasty.
The insurer denied coverage for septoplasty.
The denial is overturned. 

This female patient has a medical history of a deviated septum to the right. The patient has difficulty breathing from the right side of her nose due to a hypertrophied inferior turbinate (IT). On an visit with her otolaryngologist it was noted that the patient had an inferior turbinate reduction. The patient denied trauma to the nose that she was aware of. The patient tried over-the-counter nasal sprays and azelastine nasal spray, but they did not improve her symptoms. On physical exam, the patient's pre- and post-auricular regions were clear; both canals were clear. There was no perforation, fluid or infection. There was no inferior turbinate hypertrophy. No masses, lesions or polyps on the anterior rhinoscopy. The oropharynx was clear. The patient underwent a septoplasty. At a postoperative follow up visit, the patient reported that the patient's breathing and airway improved and that she was no longer snoring. The patient did not have any significant otolaryngeal complaints at this visit.

As per Han et al. (2015), "...linical consensus statement was developed by and for otolaryngologists and is intended to promote appropriate and, when possible, evidence-based care for patients undergoing septoplasty with or without inferior turbinate reduction. A complete definition of septoplasty with or without inferior turbinate reduction was first developed, and additional statements were subsequently produced and evaluated addressing diagnosis, medical management prior to septoplasty, and surgical considerations, as well as the appropriate role of perioperative, postoperative, and adjuvant procedures, in addition to outcomes. Additionally, a series of clinical statements were developed, such as 'Computed tomography scan may not accurately demonstrate the degree of septal deviation,' 'Septoplasty can assist delivery of intranasal medications to the nasal cavity,' 'Endoscopy can be used to improve visualization of posterior-based septal deviation during septoplasty,' and 'Quilting sutures can obviate the need for nasal packing after septoplasty.' It is anticipated that the application of these principles will result in decreased variations in the care of septoplasty patients and an increase in the quality of care." 

Per Mayo Clinic (2019), "Septoplasty is the usual way to repair a deviated septum. During septoplasty, [the] nasal septum is straightened and repositioned in the center of [the] nose. This may require [the] surgeon to cut and remove parts of your septum before reinserting them in the proper position."                     

Septoplasty was considered medically necessary for this patient. The patient has been followed for right nasal obstruction and has undergone reduction of inferior turbinate bilaterally twice. Yet, the patient has not obtained relied despite use of steroid/antihistamine sprays. The physical exam has shown right deviated nasal septum. The patient has exhausted all medical and in-office procedures to alleviate her right nasal obstruction. Literature supports that septoplasty is the next step in this patient's treatment.

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

The carrier's denial of coverage for the septoplasty should be overturned.  The medical necessity is substantiated.