Is septorhinoplasty (CPT: 30420) medically necessary for a patient with a deviated septum and nasal congestion, despite lack of documented imaging results and denial of nasal airflow obstruction, after failed conservative treatment with Flonase (fluticasone propionate)?

Septorhinoplasty (CPT 30420) is NOT Medically Necessary Without Objective Imaging Documentation

This procedure cannot be approved without the required nasal endoscopy, CT scan, or other appropriate imaging modality documenting the degree of nasal obstruction, as this is an explicit criterion that has not been met. 1, 2

Critical Missing Documentation

The Aetna policy explicitly requires "results of nasal endoscopy, CT or other appropriate imaging modality documenting degree of nasal obstruction" for rhinoplasty performed with septoplasty. 1 This criterion is marked as "NOT MET" in your case, and this alone disqualifies the procedure from medical necessity approval, regardless of other criteria being satisfied.

• CT imaging is the standard for presurgical planning and is critical for confirming the diagnosis of nasal obstruction, evaluating the extent of disease, and identifying anatomic variants. 1
• The ACR Appropriateness Criteria (2022) specifically states that multidetector CT without IV contrast is useful for confirming nasal obstruction and for presurgical planning in cases of deviated nasal septum. 1
• Objective documentation is required to correlate symptoms with physical findings before proceeding with surgery—proceeding without this evidence is a recognized pitfall. 2

Additional Concerns Undermining Medical Necessity

Beyond the missing imaging, there are several problematic elements in this case:

• The patient explicitly denies nasal airflow obstruction. The physician notes state "Though he denies nasal airflow obstruction, he does report nasal congestion symptoms." 2 This directly contradicts the requirement for "continuous nasal airway obstruction" or "gross nasal obstruction." 1, 2

• Negative Cottle maneuver bilaterally. This test assesses nasal valve function, and a negative result suggests that the obstruction may not be functionally significant at the nasal valve area, which is responsible for more than 2/3 of airflow resistance. 2, 3

• The patient is only 17 years old with a remote history of infant nasal trauma. While the provider notes he was told to wait until done growing, there is no documentation confirming skeletal maturity or why surgery is now appropriate versus waiting longer.

• Inadequate medical management documentation. While Flonase use for "greater than 6 weeks" is mentioned, there is no documentation of: 2

  • Specific medication dose, frequency, and patient compliance
  • Regular saline irrigations with technique and frequency
  • Treatment of any underlying allergic component
  • Appropriate antibiotics if bacterial sinusitis was present
  • Mechanical treatments trial (nasal dilators or strips)

What Documentation Is Required for Future Consideration

If this case is to be reconsidered, the following must be provided:

• Nasal endoscopy or CT scan showing the degree of septal deviation and its impact on the nasal airway, with specific measurements documenting obstruction. 1, 2

• Pre-operative photographs showing the standard 4-way view (anterior-posterior, right and left lateral views, and base of nose/worm's eye view) confirming any vestibular stenosis or external deformity. 2

• Comprehensive documentation of failed medical management including: 2

  • Minimum 4-week trial of intranasal corticosteroids with specific medication, dose, frequency, and compliance
  • Regular saline irrigations with documentation of technique and frequency
  • Mechanical treatments trial including nasal dilators or strips with compliance and response
  • Objective documentation of persistent symptoms despite compliance with therapies

• Patient-reported symptoms of nasal obstruction that are consistent and documented, rather than denied. The patient must acknowledge nasal airflow obstruction affecting quality of life. 2, 4

Clinical Context and Pitfalls

• Only 26% of septal deviations are clinically significant—approximately 80% of the general population has an off-center septum. 2, 5 The presence of deviation alone does not justify surgery.

• Anterior septal deviation is more clinically significant than posterior deviation as it affects the nasal valve area. 2, 3 However, without imaging, the precise location and functional impact cannot be objectively assessed.

• The primary indication appears cosmetic rather than functional, given the patient's denial of airflow obstruction and the emphasis on the "inverted-C shape deformity" and "deviated nasal dorsum." 2