Medical Necessity Determination for CPT 30120 (Excision/Shaving of Rhinophyma)
CPT 30120 is NOT medically necessary for this patient and should be DENIED.
The requested procedure code 30120 is specifically for excision or shaving of rhinophyma (a severe manifestation of rosacea), which is completely unrelated to this patient's clinical presentation of deviated septum and chronic sinus issues. The Aetna criteria clearly states that CPT 30120 is only medically necessary for treatment of bleeding or infection from rhinophyma refractory to medical therapy 1. This patient has no documented rhinophyma, rosacea, bleeding telangiectasias, or pustular eruptions.
Medical Necessity Determination for the ACTUAL Recommended Procedures
Septoplasty (CPT 30520) and Turbinate Reduction ARE medically necessary and should be APPROVED.
Clinical Criteria Met for Septoplasty
This patient clearly meets medical necessity criteria for septoplasty based on the following:
The American Academy of Allergy, Asthma, and Immunology recommends septoplasty when septal deviation causes continuous nasal airway obstruction that has not responded to at least 4 weeks of appropriate medical therapy 1
The patient has documented bilateral septal deviation on CT scan with corresponding symptoms of nasal obstruction, difficulty breathing through the right side of nose, and chronic sinus issues 1
The patient has failed conservative medical management including Astelin (azelastine) and Flonase (fluticasone) nasal sprays, and recently started allergy shots without significant improvement 1, 2
The MCG criteria explicitly state this case "APPEARS MET FOR 30520" based on septal deviation with inadequate response to medical management including intranasal steroids and antihistamines 1
Clinical Criteria Met for Turbinate Reduction
Turbinate reduction is appropriate as a combined procedure:
CT imaging confirms bilateral posterior inferior turbinate hypertrophy, which commonly accompanies septal deviation 1
The American Academy of Otolaryngology-Head and Neck Surgery states that turbinate reduction should be offered after inadequate response to medical management including intranasal steroids and antihistamines 1
Combined septoplasty with turbinate reduction provides better long-term outcomes than septoplasty alone, with the 2025 AAO-HNS guidelines specifically recommending this combined approach 1
Preservation of turbinate tissue during reduction is important to avoid complications like nasal dryness 1
Medical Necessity Determination for Eustachian Tube Balloon Dilation (CPT 69705)
Eustachian tube balloon dilation (CPT 69705) APPEARS medically necessary and should be APPROVED.
Clinical Justification
The patient meets criteria for this procedure based on:
The patient reports fluid in ears and sinuses leading to vertigo when hot, fullness buildup in ears causing hearing difficulties, and occasional vertigo 3
The MCG criteria state this case "APPEARS MET FOR 69705" for drainage or debridement procedures needed for sinusitis 1
Balloon dilation Eustachian tuboplasty (BDET) has demonstrated effectiveness for Eustachian tube dysfunction with significant postoperative improvement in tympanometry, otoscopic appearance, and validated symptom scores at 3 weeks, 6 weeks, 12 weeks, and 6 months 3
The combined approach of addressing both nasal obstruction and Eustachian tube dysfunction is logical, as septal deviation can contribute to chronic sinusitis by obstructing the ostiomeatal complex and impairing sinus ventilation and drainage 1
Evidence Supporting Combined Approach
Studies show that combined balloon tubodilation with simultaneous treatment of tubal ostial mucosa is an effective, safe, and complete treatment for tubal dysfunction in the majority of patients 4
The patient's symptoms of ear fullness, hearing difficulties, and vertigo are consistent with Eustachian tube dysfunction requiring intervention 3
Documentation Strengths Supporting Approval
The following elements strongly support medical necessity:
Objective imaging confirmation: CT scan documented bilateral septal deviation and bilateral posterior inferior turbinate hypertrophy 1
Failed conservative management: Patient tried Astelin and Flonase nasal sprays without significant improvement, and recently started allergy shots also without benefit 1, 2
Significant symptom burden: Difficulty breathing through right side of nose, fluid in ears, sinus congestion, nasal dripping, vertigo, and hearing difficulties affecting quality of life 1, 5
Long-standing symptoms: Patient has had sinus issues for a long time and previous nasal surgery 30-40 years ago 1
Correlation between anatomy and symptoms: The right-sided breathing difficulty correlates with documented septal deviation 1, 5
Common Pitfalls Avoided in This Case
Adequate medical management trial documented: The patient has tried intranasal steroids (Flonase) and antihistamines (Astelin), meeting the minimum 4-week requirement before surgical consideration 1, 2
Objective findings correlate with symptoms: CT imaging confirms the anatomical abnormalities causing the patient's complaints 1
Not all septal deviations require surgery: Only 26% of septal deviations are clinically significant, but this patient has both anatomical deviation AND corresponding symptoms with failed medical management 1, 2
Comprehensive approach: Addressing both the septal deviation, turbinate hypertrophy, and Eustachian tube dysfunction provides optimal outcomes 1, 4
Expected Outcomes and Follow-up
Up to 77% of patients achieve subjective improvement with septoplasty 1, 5
Long-term complications following septoplasty with turbinate reduction are infrequent (2.8%), with revision septoplasty being the most common at 2.5% 6
BDET shows significant postoperative improvement in validated symptom scores maintained at 6 months 3
Routine follow-up between 3-12 months post-operatively is required to assess symptom relief, quality of life, and need for ongoing care 1