Is septoplasty, submucous resection, and nasal/sinus endoscopy medically necessary for a patient with a history of acute tonsillitis, chronic post-nasal drip, nasal inflammation, and deviated septum, without documentation of prior conservative treatments?

Medical Necessity Determination: NOT APPROVED

The requested procedures (septoplasty, submucous resection, and nasal endoscopy) are NOT medically necessary at this time due to insufficient documentation of failed conservative medical management. 1, 2

Critical Missing Documentation

The fundamental requirement for surgical approval has not been met:

• No documented duration of conservative treatment trials - The American Academy of Allergy, Asthma, and Immunology requires a minimum of 4 weeks of appropriate medical therapy before septoplasty can be considered medically necessary 1, 2
• The patient lists only two medications ([MEDICATION], [MEDICATION]) with no documentation of duration, dosing, compliance, or treatment failure 1
• No evidence of saline irrigation trials - A complete medical management trial must include regular saline irrigations with documentation of technique and frequency 1
• No documentation of mechanical treatments - Trials of nasal dilators or strips must be attempted and documented before surgical intervention 1

Required Conservative Management Before Approval

Before these procedures can be approved, the following must be documented:

• Intranasal corticosteroids: Minimum 4-week trial with specific medication name, dose, frequency, and patient compliance documented 1, 2
• Saline irrigations: Regular use with documentation of technique and frequency 1
• Mechanical treatments: Trial of nasal dilators or strips with compliance and response documented 1
• Treatment of underlying allergic component: If allergies are present, appropriate management must be attempted 1
• Objective documentation of treatment failure: Persistent symptoms despite compliance with all above therapies must be clearly documented 1

Assessment of Individual Procedures

Septoplasty (CPT 30520)

• UNDETERMINED - While the patient has documented septal deviation (50-75% obstruction) on physical exam and CT scan, the American Academy of Allergy, Asthma, and Immunology requires documented failure of at least 4 weeks of appropriate medical therapy before septoplasty is medically necessary 1, 2
• Only 26% of septal deviations are clinically significant enough to require surgery; the presence of deviation alone does not justify surgical intervention 1

Bilateral Inferior Turbinate Reduction (CPT 30140 x2)

• UNDETERMINED - The American Academy of Otolaryngology-Head and Neck Surgery states that turbinate reduction should only be offered after inadequate response to medical management including intranasal steroids and antihistamines 1, 2
• While marked turbinate hypertrophy is documented on exam, there is no documentation of failed medical management or how symptoms affect quality of life 1

Nasal/Sinus Endoscopy (CPT 31240)

• NOT MET - The American College of Allergy and Clinical Immunology requires that chronic rhinosinusitis must not have responded to 1 or more months of medical treatment (nasal steroids, antibiotics) before functional endoscopic sinus surgery is indicated 1
• The diagnosis of "chronic pansinusitis" is listed, but there is no documentation of chronic rhinosinusitis symptoms lasting >8 weeks, no documentation of medical management trials, and no correlation between CT findings and clinical symptoms 1

Clinical Context and Pitfalls

Important Considerations

• Approximately 80% of the general population has an off-center nasal septum, but only 26% have clinically significant deviation causing symptoms requiring surgical intervention 1, 2
• The presence of acute tonsillitis and chronic post-nasal drip may be due to other causes such as allergic rhinitis, which should be treated medically first 2
• Intermittent Afrin use does not constitute appropriate medical therapy and should not be considered as part of conservative management 1

What Would Make This Approvable

• Document a minimum 4-week trial of intranasal corticosteroids with specific details of medication, dose, frequency, and compliance 1
• Document regular saline irrigation use with technique and frequency 1
• Document trial of mechanical treatments (nasal dilators/strips) with compliance and response 1
• Document persistent nasal obstruction symptoms affecting quality of life despite compliance with all conservative therapies 1
• For the endoscopic sinus surgery component, document chronic rhinosinusitis symptoms lasting >8 weeks with failed medical management including antibiotics and nasal steroids 1

Recommendation for Resubmission

DENY with option to resubmit after completing and documenting a minimum 4-week trial of comprehensive medical management including intranasal corticosteroids, saline irrigations, and mechanical treatments, with clear documentation of treatment failure and persistent symptoms affecting quality of life. 1, 2