Are septoplasty and thyroidectomy medically indicated for a 61-year-old female with a deviated septum, chronic maxillary sinusitis, and a suspicious thyroid nodule?

Medical Necessity Assessment for Septoplasty and Thyroidectomy

Septoplasty (CPT 30520): NOT MEDICALLY NECESSARY at this time

Septoplasty is not medically indicated for this patient because there is no documentation of failed medical management for nasal obstruction, which is an absolute requirement before surgical intervention can be considered. 1

Critical Missing Documentation

• No evidence of 4+ weeks of appropriate medical therapy - The American Academy of Allergy, Asthma, and Immunology requires documented failure of at least 4 weeks of medical management before septoplasty can be considered medically necessary 1, 2, 3

• Required medical therapies not documented:

  • Intranasal corticosteroids (specific medication, dose, frequency, compliance) 1, 2
  • Regular saline irrigations (technique and frequency) 1, 2
  • Appropriate antibiotics for documented bacterial sinusitis 1, 2
  • Treatment of underlying allergic component if present 1, 2

Why This Patient Does Not Meet Criteria

• Patient is explicitly "not symptomatic at all" - The progress note from 10/15/2025 clearly states the patient "was not symptomatic at all" regarding her sinus issues, and the physician "decided not to move forward" with surgery 1

• Decreased smell is not an indication for septoplasty - The physician correctly noted that "studies have shown that smell does not improve after nasal surgery," and this was the patient's only complaint 1

• Chronic maxillary sinusitis alone does not justify septoplasty - The presence of chronic sinusitis without documented nasal airway obstruction symptoms and failed medical management does not meet medical necessity criteria 1, 2

Clinical Context

• The left maxillary sinus opacification was initially thought to be blood from her fall (3/2/25) and has shown "no change" on follow-up imaging 1
• The physician appropriately discussed surgery but correctly deferred given lack of symptoms 1
• Only 26% of septal deviations are clinically significant enough to warrant surgery 1, 3

Required Steps Before Reconsideration

If the patient develops continuous nasal airway obstruction symptoms in the future, the following must be documented: 1, 2

• Minimum 4-week trial of intranasal corticosteroids with compliance documentation
• Regular saline irrigations with documented technique and frequency
• Mechanical treatments (nasal dilators/strips) with compliance and response
• Persistent symptoms despite compliant use of above therapies
• Objective documentation that symptoms are continuous and severe, not intermittent

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Thyroidectomy (CPT 60240): MEDICALLY NECESSARY

Thyroidectomy is medically indicated for this patient based on the presence of a 2.8 cm TR 3 thyroid nodule with dysphagia and substernal extension, meeting criteria for high-risk features requiring surgical intervention. 4

Criteria Met for Surgical Intervention

• TR 3 nodule measuring 2.8 cm - Ultrasound from 11/3/2025 shows a dominant 2.8 cm TR 3 nodule in the left thyroid lobe with recommendation for FNA 4

• Symptomatic thyroid disease - Patient reports "some difficulty swallowing which may be related to the thyroid," documented as dysphagia, pharyngoesophageal phase 4

• Substernal extension - Progress note from 10/15/2025 documents "substernal" thyroid with "extrathyroidal cyst" noted in 2021 4

• Size >4 cm consideration - While the dominant nodule is 2.8 cm, the presence of multinodular goiter with substernal extension and symptoms constitutes an indication for total thyroidectomy 4

Surgical Approach Recommended

Total thyroidectomy is the appropriate procedure based on: 4

• Patient age 61 years (>45 years is an indication for total thyroidectomy over lobectomy) 4
• Multinodular goiter with substernal component 4
• Symptomatic disease with dysphagia 4
• TR 3 nodule requiring tissue diagnosis 4

Preoperative Requirements

• FNA should be performed if not already done - The ultrasound recommends FNA for the 2.8 cm TR 3 nodule for further evaluation 4

• Vocal cord mobility assessment - Must be evaluated preoperatively to document baseline function 4

• CT/MRI consideration - Given substernal extension, cross-sectional imaging without iodinated contrast should be considered for surgical planning 4

Important Caveats

• If FNA returns as papillary carcinoma, additional staging and surgical planning per NCCN guidelines would be required, potentially including lymph node assessment 4

• Postoperative TSH suppression - Patient will require levothyroxine therapy postoperatively, with TSH targets depending on final pathology 4

• Calcium and vitamin D supplementation - Given risk of hypoparathyroidism with total thyroidectomy, ensure adequate calcium (1200 mg/d) and vitamin D (1000 units/d) intake 4