Do septoplasty (CPT 30520) and nasal fracture reduction (CPT 30930) meet medical necessity criteria for a patient with a slightly deviated septum and aesthetic goals for surgery?

DECISION: DENY ALL CODES - COSMETIC INDICATION

This request for septoplasty (CPT 30520) and bilateral nasal fracture reduction (CPT 30930 x2) does NOT meet medical necessity criteria because the patient explicitly denies nasal obstruction symptoms, has purely aesthetic goals, and lacks documentation of failed medical management required for functional nasal surgery. 1

Critical Deficiencies in Medical Necessity Documentation

Patient's Stated Goals Are Purely Cosmetic

• The clinical documentation explicitly states the patient's goals as "sculpting of nasal bones," "straight Dorsum," "narrower DALs," and adjusting the nasolabial angle from 95 to 100 degrees - all aesthetic objectives 1
• Most critically, the patient "denies sinus issues, congestion, or SOB" - this directly contradicts any claim of functional impairment 1
• The American Academy of Allergy, Asthma, and Immunology requires documented symptoms of nasal obstruction (nasal congestion, difficulty breathing through the nose, difficulty sleeping) to justify surgical intervention 1

Absence of Required Medical Management

• No documentation exists of any trial of medical therapy - the record shows zero attempts at intranasal corticosteroids, saline irrigations, or mechanical nasal dilators 1, 2
• The American Academy of Allergy, Asthma, and Immunology mandates a minimum 4-week trial of medical management including intranasal corticosteroids, saline irrigations, and mechanical treatments before septoplasty can be considered medically necessary 1, 2
• Without documented failure of conservative therapy, surgery cannot be justified regardless of anatomical findings 1

Minimal Anatomical Deviation

• The examination notes only "septum off to right side by 2mm" - this represents minimal deviation 1
• Approximately 80% of the general population has some septal asymmetry, but only 26% have clinically significant deviation causing symptoms requiring surgical intervention 1
• The presence of anatomical deviation alone, without functional impairment and failed medical management, does not justify surgery 1, 2

Analysis of Specific CPT Codes

CPT 30520 (Septoplasty)

• Criteria NOT met: Patient denies nasal obstruction symptoms that septoplasty is designed to treat 1
• The American Academy of Otolaryngology recommends septoplasty only for septal deviation causing continuous nasal airway obstruction that has not responded to appropriate medical therapy 1
• This patient has no documented obstruction symptoms and no medical therapy trial 1

CPT 30930 x2 (Bilateral Nasal Fracture Reduction)

• Criteria NOT met: No documentation of acute nasal fracture or traumatic injury 1
• The clinical notes describe "long standing nasal bone deformity" - this indicates chronic anatomical variation, not acute fracture requiring reduction 1
• Nasal fracture reduction is typically performed within 3 weeks of acute injury before significant healing occurs 1
• The procedure described appears to be osteotomies for cosmetic rhinoplasty reshaping ("sculpting of nasal bones"), not fracture reduction 3

What Would Be Required for Medical Necessity

Functional Symptoms Documentation Needed

• Patient-reported nasal obstruction affecting quality of life (congestion, mouth breathing, sleep disturbance) 1, 2
• Symptoms must be consistent and documented over time, not denied as in this case 2
• Objective correlation between symptoms and physical examination findings 1

Medical Management Trial Required

• Minimum 4-week trial of intranasal corticosteroid spray with documentation of medication, dose, frequency, and compliance 1, 2
• Regular saline irrigations with documentation of technique and frequency 1
• Trial of mechanical nasal dilators or strips with documentation of compliance and response 1
• Clear documentation of persistent symptoms despite adherence to above therapies 1

Imaging Requirements

• CT imaging would be required to confirm clinically significant septal deviation and document degree of obstruction 2
• Nasal endoscopy or CT must show specific measurements documenting obstruction, not just presence of deviation 2

Common Pitfall Highlighted in This Case

• The presence of anatomical deviation does not equal medical necessity - only 26% of septal deviations are clinically significant, and assuming all deviations require surgical correction is a documented pitfall 1
• The insurance policy correctly identifies this as cosmetic based on the patient's stated aesthetic goals and denial of functional symptoms 1
• The procedure described is an "Open Septorhino with septal reset" - this is rhinoplasty terminology indicating cosmetic nasal reshaping, not functional septoplasty 3, 1

FINAL DETERMINATION: All requested CPT codes (30520,30930 x2) are DENIED as cosmetic procedures not meeting medical necessity criteria due to absence of functional symptoms, lack of medical management trial, and patient's explicitly stated aesthetic goals. 1, 2