Are septoplasty and removal of bone and cartilage for graft medically necessary for a patient with a deviated nasal septum and breathing difficulties?

Medical Necessity Assessment for Septoplasty and Associated Procedures

Primary Determination: Septoplasty (CPT 30520) Does NOT Meet Medical Necessity Criteria

The proposed septoplasty and all associated grafting procedures are NOT medically necessary because the patient has failed to complete the required minimum 4-week trial of appropriate medical management. 1, 2 Occasional use of allergy spray when symptoms are bad does not constitute adequate conservative therapy and represents a critical documentation gap that prevents approval. 2

---

Critical Missing Documentation

Inadequate Medical Management Trial

• The American Academy of Allergy, Asthma, and Immunology requires documented failure of at least 4 weeks of appropriate medical therapy before septoplasty can be considered medically necessary. 1, 2
• The patient's "occasional use of nasal sprays when allergies are bad" is explicitly inadequate and does not meet the threshold for failed medical management. 2
• Intermittent Afrin use (if that is what was used) is inappropriate chronic management and does not constitute medical therapy. 2

Required Conservative Treatments Not Documented

• Regular daily intranasal corticosteroids (not occasional use) with specific medication, dose, frequency, and patient compliance documentation for minimum 4 weeks. 2
• Daily saline irrigations with documentation of technique and frequency. 2
• Mechanical treatments trial including nasal dilators or strips with documentation of compliance and response. 2
• Objective documentation of treatment failure including persistent symptoms despite compliance with above therapies. 2

---

Clinical Context Supporting Potential Future Approval

Anatomical Findings That Would Support Surgery (After Medical Management)

• The patient has documented left septal deviation with bilateral inferior turbinate hypertrophy on physical examination. 1
• CT scan confirms mild scattered ethmoid and bilateral maxillary sinus disease with chronic nasal bone fractures and mildly deviated nasal septum. 1
• Anterior septal deviation is more clinically significant than posterior deviation as it affects the nasal valve area responsible for more than 2/3 of airflow resistance. 2
• The patient reports harder breathing on the right side compared to left, indicating functional impairment. 1

Important Caveat About Septal Deviation

• Approximately 80% of the general population has an off-center nasal septum, but only about 26% have clinically significant deviation causing symptoms. 1, 2
• Not all septal deviations require surgical correction—the presence of deviation alone does not justify surgery without documented symptomatic obstruction and failed medical management. 1, 2

---

Evidence-Based Outcomes When Criteria Are Met

Septoplasty Effectiveness

• When appropriately indicated after failed medical management, septoplasty achieves subjective improvement in 77% of patients. 2
• The 2024 NAIROS randomized controlled trial demonstrated that septoplasty with or without turbinate reduction is significantly more effective than medical management, with mean SNOT-22 scores 20.0 points lower (better) at 6 months (p < 0.0001). 3
• A 2022 randomized clinical trial confirmed that surgical correction of deviated nasal septum by septoplasty improves nasal obstruction better than nonsurgical management at 6 months post-surgery. 4

Cost-Effectiveness Considerations

• Septoplasty has only a 15% probability of being cost-effective at 12 months at a £20,000 willingness-to-pay threshold, but this increases to 99% at 24 months and 100% at 36 months. 3
• This supports the importance of ensuring appropriate patient selection through documented failed medical management before proceeding with surgery. 3

---

Status of Associated Procedures (CPT 20902,20910,20912,21230,21235,15760,15770)

All Grafting Procedures Are Predicated on Primary Procedure

• Cartilage and bone graft harvest procedures (CPT 20902,20910,20912,21230,21235) are adjunctive procedures that would only be necessary if the primary septoplasty were medically necessary. 2
• Since the primary procedure does not meet criteria due to inadequate medical management, these grafting procedures are also not medically necessary at this time. 2
• Septal batten grafts and spreader grafts are appropriate surgical techniques when nasal valve collapse is present and septoplasty alone would be insufficient, but only after medical management has failed. 5, 1, 6

Composite Grafts (CPT 15760,15770)

• Composite skin grafts and derma-fat-fascia grafts are similarly predicated on the primary procedure meeting medical necessity criteria. 2
• These would only be considered if complex reconstruction were required after appropriate septoplasty indication is established. 5

---

Pathway to Potential Future Approval

Required Documentation Before Resubmission

1. Complete a minimum 4-week trial of daily intranasal corticosteroids (such as fluticasone or mometasone) with documentation of medication name, dose, frequency, and patient compliance. 1, 2
2. Implement regular saline irrigations (twice daily) with documentation of technique and frequency. 1, 2
3. Trial mechanical treatments including nasal dilators or external nasal strips with documentation of compliance and response. 2
4. Document persistent symptoms despite compliance with all above therapies, including continued nasal obstruction affecting quality of life. 1, 2

Turbinate Reduction Considerations

• The American Academy of Otolaryngology states that turbinate reduction should only be offered after inadequate response to medical management including intranasal steroids and antihistamines. 2
• Bilateral inferior turbinate hypertrophy is documented on examination, which commonly accompanies septal deviation and may require combined surgical approach after medical management fails. 1, 2
• Submucous resection with outfracture is the most effective surgical therapy for turbinate hypertrophy with the fewest complications compared to turbinectomy, laser cautery, electrocautery, or cryotherapy. 2

---

Common Pitfalls to Avoid

• Proceeding with surgery without objective evidence correlating symptoms with physical findings and documented failed medical management is the most common pitfall. 2
• Assuming all septal deviations require surgical correction when only 26% are clinically significant. 1, 2
• Not documenting the specific duration, medications, doses, and patient compliance with medical therapy. 1, 2
• Failing to address underlying allergic rhinitis appropriately before considering surgery. 1, 2
• Not preserving as much turbinate tissue as possible during surgery to avoid complications like nasal dryness. 2