Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 23-year-old male who underwent septorhinoplasty, bilateral inferior turbinoplasty, and submucous resection of the nasal septum on 3/11/20. The patient has requested reimbursement for nasal surgery performed on 3/11/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature. The physician reviewer found that while the provider reported simply that there was a severely deviated nasal septum, no further information was received for review. There is no physical description of the reported nasal deviation from either speculum view or from the performed nasal endoscopy. No imaging of the nasal septum was performed. Symptoms of nasal obstruction were fluctuating, with allergic rhinitis present seasonally from August through September. Fluctuating symptoms of nasal obstruction due to allergy are not diagnostic of a physical functional deformity of the nasal septum. Symptoms of breathing obstruction were poor sleeping and waking with a dry mouth. No symptoms of daytime breathing obstruction were received for review. The prior history of medical management included self-managed use of Claritin and Afrin. No documented history of attempted medical management of breathing obstruction, including the use of Flonase, was received for review. Nasal deviation was mild on the photographs received for review. Gottlieb and Punjabi stated that the most common presenting symptom of OSA is excessive sleepiness. In a study of internal nasal dimensions and obstructive sleep apnea syndrome (OSAS), Trindade and colleagues stated, aThere were no significant differences in the cross-sectional areas and nasal volumes between individuals with primary snoring-mild obstructive sleep apnea syndrome and moderate-severe obstructive sleep apnea syndrome. Differently to the raised hypothesis, our results suggest that there is no association between internal nasal dimensions and severity of obstructive sleep apnea syndrome.a Cao and colleagues stated, aThe co-existence of allergic rhinitis (AR) and obstructive sleep apnea (OSA) is a common phenomenon in clinical practice. AR has long been considered a risk factor for OSAaPatients with AR were more likely to become habitual snorers and had increasing risk of SDB (sleep disordered breathing).aThis patientas complaints for nasal surgery were not sleeping well and waking with a dry mouth. He has allergic rhinitis, a risk factor for obstructive sleep apnea syndrome. His nasal symptoms fluctuate seasonally and do not reflect a fixed nasal airway deformity. There is no history of medical treatment for allergic rhinitis, including the use of Flonase. There are no objective physical findings reported to support a diagnosis of a severely functionally deviated nasal septum. Photographs received for review do not document nasal deviation to a functionally significant extent to cause nasal breathing obstruction. Based on the medical history received for review, septorhinoplasty, bilateral inferior turbinoplasty, and submucous resection of the nasal septum were not medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The medical history received for review does not support that the patient has an abnormal structure of the body. There is a lack of medical history and physical findings to support a diagnosis of functional nasal airway obstruction. The California reconstructive surgery statute does not apply to this patient. Therefore, nasal surgery performed on 3/11/20 was not reconstructive in nature.