Is rhinoplasty (CPT code 30450) and autologous graft (CPT code 15769) medically necessary for a 70-year-old female with chronic nasal obstruction, septal deviation, septal perforation, and external nasal deformity after prior trauma, despite persistent symptoms despite medical therapy with budesonide (corticosteroid) and azelastine (antihistamine) nasal spray?

Medical Necessity Assessment for Rhinoplasty (CPT 30450) and Autologous Graft (CPT 15769)

Direct Recommendation

Rhinoplasty (CPT 30450) is medically necessary for this 70-year-old female with post-traumatic nasal deformity, septal deviation, septal perforation, and persistent nasal obstruction despite medical therapy; however, certification cannot be granted until adequate pre-operative photographs demonstrating external nasal deformity are submitted, as this is a mandatory documentation requirement per the clinical policy bulletin. 1, 2

Critical Missing Documentation

The primary barrier to approval is inadequate photographic documentation. The CPB explicitly requires:

• Standard 4-way view photographs: anterior-posterior, right and left lateral views, and base of nose (worm's eye view) confirming vestibular stenosis 1, 2
• The attached pre-operative photo is noted as "unclear" in the request, which fails to meet this mandatory criterion
• Without proper photographic documentation showing external nasal deformity, medical necessity cannot be definitively established even when all other criteria are met 1, 2

Analysis of Met Criteria

Functional Obstruction Requirements - MET

The patient satisfies the following mandatory criteria for functional rhinoplasty:

• Prolonged, persistent obstructed nasal breathing: Documented right greater than left nasal congestion with chronic crusting and nosebleeds 1, 2
• Physical examination confirming moderate to severe vestibular obstruction: Significant asymmetry with right ala inserting more inferior and medial, 1cm anterior septal perforation, rightward dorsal septal deviation 3
• Airway obstruction will not respond to septoplasty alone: The external nasal deformity with significant alar asymmetry and tip deviation requires rhinoplasty techniques beyond simple septal correction 3
• Significant symptoms: Chronic nasal obstruction, crusting, and nosebleeds affecting quality of life 1, 2

Medical Management Requirements - MET

• Conservative management >4 weeks: Patient has been on budesonide rinses and mupirocin ointment for approximately 7 months with only partial symptom control 1, 2
• Appropriate medical therapy: Intranasal corticosteroids (budesonide) and topical antibiotics have been trialed 3
• The patient reports these treatments "help a little bit" but do not fully control obstruction, crusting, or nosebleeds, documenting treatment failure 1, 2

Anatomical Documentation - MET

• CT scan documentation: Shows leftward septal deviation with septal perforation and mild pansinusitis 1, 2
• Nasal endoscopy findings: 1 x 1.5 cm anterior perforation with bleeding edges, rightward dorsal deviation, significant alar asymmetry 1, 2
• Relevant trauma history: Kicked in the face by horse 10 years ago with prior reconstructive surgery, creating acquired nasal deformity 3

Medical Necessity for Autologous Graft (CPT 15769)

The autologous graft is medically necessary as reconstructive surgery for post-traumatic nasal deformity. 4, 5

Justification for Grafting

• Septal perforation repair: The 1 x 1.5 cm anterior perforation requires grafting material for closure 3
• Structural support: Post-traumatic deformity with significant asymmetry requires cartilage grafts for repositioning and reinforcement of the nasal framework 3
• Autologous grafts are standard of care: They provide reliable long-term outcomes with low rates of infection, resorption, and extrusion compared to allografts or alloplasts 4, 5
• Multiple grafting techniques indicated: Spreader grafts for middle third concavity, batten grafts for alar repositioning, and onlay grafts for tip symmetry are all appropriate for this complex post-traumatic deformity 3

Septal Perforation Repair (CPT 30630) - CERTIFIED

This procedure is clearly medically necessary and meets all CPB criteria. 1, 2

• Repair of nasal septal perforations is explicitly listed as medically necessary in the CPB 1
• The 1 x 1.5 cm anterior perforation with bleeding edges is causing symptoms (nosebleeds, crusting) 1, 2
• Conservative management with mupirocin ointment has failed to control symptoms 1, 2

Algorithmic Approach to Approval

Step 1: Verify Photographic Documentation

• If adequate 4-way photographs present: Proceed to Step 2
• If photographs inadequate or unclear: Request resubmission with proper documentation before proceeding 1, 2

Step 2: Confirm Medical Management Duration

• Minimum 4 weeks of appropriate therapy required: This patient has 7 months documented 1, 2
• Must include intranasal corticosteroids: Budesonide rinses documented 3
• Document treatment failure: Patient reports persistent symptoms despite therapy 1, 2

Step 3: Assess Anatomical Severity

• External deformity present: Significant alar asymmetry, tip deviation, rightward deviation of upper/middle/lower thirds 3
• Internal obstruction documented: CT scan and endoscopy confirm septal deviation and perforation 1, 2
• Functional impairment: Continuous nasal obstruction affecting quality of life 1, 2

Step 4: Determine Surgical Necessity

• Septoplasty alone insufficient: External deformity requires rhinoplasty techniques 3
• Grafting required: Septal perforation and structural deficiency necessitate autologous grafts 4, 5
• Combined approach appropriate: Post-traumatic deformity with multiple anatomical abnormalities 3

Common Pitfalls and Caveats

Documentation Pitfalls

• Inadequate photographs are the most common reason for denial: The "unclear" pre-operative photo in this case is a critical deficiency that must be corrected 1, 2
• Failure to document medical management duration: While met in this case, many requests lack clear timeline of conservative therapy 1, 2
• Insufficient description of functional impairment: Must document how obstruction affects daily activities and quality of life 1, 2

Clinical Considerations

• Septal perforation complicates surgery: The 1 x 1.5 cm anterior perforation increases surgical complexity and risk of complications including enlargement, saddle nose deformity, and persistent crusting 6, 7
• Prior trauma and surgery increase revision risk: This patient has already had one reconstructive procedure, placing her at higher risk for complications including septal perforation enlargement, adhesions, and recurrent deformity 6, 5, 7
• Age considerations: At 70 years old, healing may be slower and complication rates potentially higher, though age alone is not a contraindication 6, 7
• Chronic sinusitis requires ongoing management: The mild pansinusitis on CT will require continued medical therapy postoperatively 3, 1, 2

Surgical Planning Considerations

• Open approach preferred for complex revision: Given prior surgery and multiple deformities, open rhinoplasty provides better visualization and control 3, 5
• Cartilage graft harvest planning: Septal cartilage may be limited due to prior surgery and perforation; ear or rib cartilage may be necessary 4, 5
• Perforation repair timing: Some surgeons prefer staged procedures, but combined approach is reasonable given symptom severity 3

Final Determination

CONDITIONAL APPROVAL RECOMMENDED pending submission of adequate pre-operative photographs showing:

• Anterior-posterior view demonstrating nasal deviation
• Right and left lateral views showing profile deformity
• Base view (worm's eye view) confirming vestibular stenosis and alar asymmetry 1, 2

Once photographic documentation is complete, all medical necessity criteria are satisfied for:

• CPT 30450 (Rhinoplasty): Post-traumatic external deformity with functional obstruction
• CPT 30630 (Septal perforation repair): Already certified
• CPT 15769 (Autologous graft): Reconstructive grafting for structural support and perforation closure 3, 1, 2, 4, 5