Are septoplasty (CPT 30520), removal of bone for graft (CPT 20902), and removal of cartilage for graft (CPT 20912) medically necessary for a patient with a deviated nasal septum (DNS), nasal obstruction, facial pressure, and sinus infection?

Medical Necessity Cannot Be Determined - Insufficient Documentation

Based on current evidence, these procedures (CPT 30520 septoplasty, CPT 20902 bone graft harvest, CPT 20912 cartilage graft harvest) cannot be approved as medically necessary due to inadequate documentation of failed conservative management and incomplete clinical information. The American Academy of Allergy, Asthma, and Immunology requires a minimum of 4 weeks of documented medical therapy before septoplasty can be considered medically necessary 1.

Critical Missing Documentation

The following essential elements are absent and must be provided before medical necessity can be established:

• Duration of conservative treatment - A minimum 4-week trial of intranasal corticosteroids with specific medication, dose, frequency, and patient compliance documentation is required 1, 2
• Complete medical management trial - Must include intranasal corticosteroids, regular saline irrigations, and mechanical treatments (nasal dilators/strips) with documentation of technique, frequency, compliance, and response 1, 3
• Objective documentation of treatment failure - Persistent symptoms despite compliance with medical therapies must be documented 1
• Full examination notes - Physical examination must document the degree of septal deviation, location (anterior vs posterior), and percentage of airway obstruction 2
• Imaging confirmation - CT imaging is recommended by the American College of Radiology as the standard for presurgical planning to confirm diagnosis, evaluate extent of disease, and identify anatomic variants 2

Why Conservative Management Documentation Is Essential

• Only 26% of septal deviations are clinically significant despite 80% of the general population having off-center septums 1, 3
• The American Academy of Otolaryngology recommends that comprehensive medical management attempts should be documented, including duration of treatment and evidence of failure of medical therapy, before surgical intervention 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, but without imaging and detailed examination, the precise location and functional impact cannot be objectively assessed 2

Regarding Adjunctive Procedures (CPT 20902 and 20912)

• Cartilage and bone graft harvest (CPT 20902,20912) are adjunctive procedures that would only be medically necessary if the primary septoplasty procedure meets medical necessity criteria 1
• These grafts are used for septal reconstruction following septoplasty when tissue preservation and realignment techniques are employed, as recommended by the American Academy of Otolaryngology 1
• Auricular cartilage grafts can serve as safe, effective alternatives when septal cartilage is insufficient, with low complication rates and no graft resorption in long-term follow-up 4

What Must Be Documented for Future Consideration

Medical Management Trial (Minimum 4 Weeks):

• Intranasal corticosteroid spray - specific medication name, dose, frequency, duration, and patient compliance 1, 2
• Regular saline irrigations - technique used, frequency, and patient adherence 1, 3
• Mechanical treatments - nasal dilators or strips with documentation of compliance and response 1
• Treatment of underlying allergic component if present 2

Clinical Documentation:

• Detailed symptom history including duration, severity, and impact on quality of life 1
• Complete physical examination findings documenting degree and location of septal deviation 2
• Objective measures of nasal obstruction correlating with symptoms 1
• Documentation that symptoms persist despite adherence to medical therapy 1

Common Pitfalls to Avoid

• Assuming all septal deviations require surgery - Only clinically significant deviations causing continuous nasal airway obstruction warrant surgical intervention 1, 3
• Proceeding without objective evidence - Symptoms must correlate with physical findings and imaging 1
• Inadequate medical management trial - Intermittent Afrin use does not constitute appropriate medical therapy according to the Journal of Allergy and Clinical Immunology 1
• Insufficient documentation timeframe - The "unknown period of time" for conservative treatment is inadequate; specific duration must be documented 1