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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for submucosal resection inferior turbinate and rhinoplasty primary, including major septal repair for treatment of the enrollees deviated septum. Findings: The physician reviewer has found that there is sufficient support in the documentation provided as well as in the medical literature for the submucosal resection inferior turbinate. The patient has significant nasal deformity and nasal airway obstruction as a direct result of a previous nasal fracture.  This is supported by the medical documentation from two providers and a review of the photographs. Rohrich and Ahmad, noted that In patients with nasal airway obstruction, it is important to restore the nasal airway.  As such, submucosal resection inferior turbinate is medically necessary for the treatment of this patients medical condition.With regards to the rhinoplasty, including major septal repair, these requested services are also medically necessary for treatment of this patient. She has a functional impairment of partial nasal obstruction, as well as significantly abnormal appearance of the nasal dorsum and nasal bones. The patient has had significant nasal trauma producing a predictable pattern of deformity and impairment. Rhinoplasty with septoplasty would be consistent with the standard of care in the setting of residual nasal deformity and nasal airway obstruction because of nasal injury. For these reasons, the requested rhinoplasty, including major septal repair is medically necessary for treatment of this patient.Additionally, the patients nose constitutes an abnormal structure of the body. She is noted to have an abnormal deformity secondary to trauma, and intervention should be considered reconstructive in nature.  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 performed to approximate a normal appearance. In this patients case, she is noted to have suffered multiple nasal injuries resulting in nasal deformity and nasal obstruction. The patients deformity includes deviated nasal bones. Submucosal resection inferior turbinate will improve function. The rhinoplasty which includes the external nasal bony treatment, would be performed in order to create a more normal appearance. Based on the photographs, more than a minimal improvement would be expected. Overall, submucosal resection inferior turbinate as well as rhinoplasty, including major septal repair are reconstructive in nature and not cosmetic.Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment 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.