Is septoplasty and rhinoplasty medically indicated for an 18-year-old female with a history of nasal trauma, deviated nasal septum, nasal valve collapse, and difficulty breathing out of the left side of her nose, who has not responded to 60 days of medical management with nasal steroids?

Medical Necessity Determination: Septoplasty and Rhinoplasty Not Approved Without Required Documentation

Based on the insurance criteria and current clinical guidelines, this septorhinoplasty cannot be approved as medically necessary at this time due to missing critical documentation: specifically, the absence of nasal endoscopy, CT imaging, and complete pre-operative photographs (standard 4-way view). While the patient has a documented history of nasal trauma with persistent symptoms and failed medical management, the insurance policy explicitly requires objective documentation that has not been provided 1, 2.

Critical Missing Documentation

Required Imaging and Diagnostic Studies

• Nasal endoscopy or CT scan is mandatory to objectively document the degree of septal deviation and its impact on the nasal airway, with specific measurements showing obstruction 2.
• The American College of Radiology recommends CT imaging as the standard for presurgical planning, critical for confirming the diagnosis of nasal obstruction, evaluating the extent of disease, and identifying anatomic variants 2.
• Without imaging, the precise location and functional impact of the septal deviation cannot be objectively assessed, even though anterior septal deviation is more clinically significant than posterior deviation as it affects the nasal valve area 2.

Required Photographic Documentation

• Pre-operative photographs are mandatory before rhinoplasty can be approved as medically necessary, including anterior-posterior view, right and left lateral views, and base of nose (worm's eye view) to demonstrate external nasal deformity that correlates with the side of greatest obstruction 1.
• The insurance criteria explicitly state that only one side view image is available, which does not meet the standard 4-way view requirement 1.
• Photographs must demonstrate an external nasal deformity to justify rhinoplasty as a medically necessary procedure rather than cosmetic 3.

Why Both Procedures Are Indicated (If Documentation Were Complete)

Septoplasty Component - Clearly Indicated

• Septoplasty is medically necessary when septal deviation causes continuous nasal airway obstruction that has not responded to at least 4 weeks of appropriate medical therapy, which this patient meets with 60 days of nasal steroid failure 4.
• The patient has documented caudal septal right deviation with septum residing in right nasal cavity and right greater than left intranasal valve collapse with improvement in Cottle maneuver, supporting functional impairment 4.
• Approximately 80% of the population has some septal asymmetry, but only 26% have clinically significant deviation requiring surgical intervention 4, 1.

Rhinoplasty Component - Medically Justified But Requires Documentation

• The American Academy of Otolaryngology recognizes that correction of the deviated nose requires septal correction plus manipulation of the external bony pyramid and upper lateral cartilages, which constitutes functional septorhinoplasty rather than septoplasty alone 1.
• Septorhinoplasty is medically indicated for patients with acquired/traumatic nasal deformities where external framework deviation contributes to nasal valve collapse, which applies to this patient with documented trauma in eighth grade 1.
• The physician's examination documents "wide nasal bones deviated off towards left side, dorsum deviated towards left with nasal tip deviated towards left" and "right > left intranasal valve collapse", indicating that external nasal framework correction is necessary for functional improvement 1.

Clinical Rationale for Combined Approach

Why Septoplasty Alone Would Be Insufficient

• Nasal valve abnormalities can produce symptoms due to increased collapsibility of the nasal valve, and surgical intervention is directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle 5.
• The patient has documented right greater than left internal nasal valve collapse which improves bilaterally with Cottle maneuver, indicating that external support is needed 6.
• Small anatomic disturbances in the region of the nasal valve can produce significant airway obstruction by narrowing the nasal valve angle, which normally should be 10-15 degrees between the caudal end of the upper lateral cartilage and the nasal septum 5.

Surgeon's Concern About Cartilage Availability

• The surgeon notes "long nasal bones and a very short nose which is overrotated" with concern that "there will not be sufficient cartilage within her nose for grafting purposes" to set her septum straight 1.
• This justifies the planned rib cartilage harvest for spreader grafts and caudal septal extension graft, as septal cartilage grafts are useful in surgical management of nasal respiratory impairment due to nasal valve incompetence 6.
• Maintaining the position of the tip and the columella is one of the main issues to avoid typical postoperative deformities, and the stability of the caudal septum in septorhinoplasty is the key for a predictable result 7.

What Documentation Must Be Obtained for Approval

Imaging Requirements

• Nasal endoscopy documenting the degree of nasal obstruction, showing the septal deviation, turbinate hypertrophy, and nasal valve collapse 2.
• CT scan of the sinuses and nasal cavity to confirm the diagnosis, evaluate the extent of deviation, and assist with presurgical planning 2.
• The American College of Radiology states that multidetector CT without IV contrast is useful for confirming nasal obstruction and for presurgical planning in cases of deviated nasal septum 2.

Photographic Requirements

• Complete standard 4-way view photographs: anterior-posterior, right and left lateral views, and base of nose (worm's eye view) 1.
• These photographs must demonstrate the external nasal deformity including the deviated nasal bones, deviated dorsum, and deviated nasal tip documented on examination 1.
• The base view is particularly important as it can confirm vestibular stenosis and show the relationship between the columella and nasal tip 3.

Common Pitfalls and Caveats

Documentation Pitfalls

• Only 26% of septal deviations are clinically significant, and assuming all septal deviations require surgical correction without objective documentation is a common pitfall 4.
• Proceeding with surgery without objective evidence correlating symptoms with physical findings is inappropriate, even when the clinical history is compelling 4.
• The insurance criteria explicitly state that "if there is an external nasal deformity, pre-operative photographs showing the standard 4-way view" are required, making this non-negotiable 1.

Medical Management Verification

• While the patient has completed 60 days of nasal steroids, ensure documentation includes specific medication, dose, frequency, and patient compliance 1.
• Regular saline irrigations should also be documented as part of comprehensive medical management 2.
• The patient takes Zyrtec for seasonal allergies, but treatment of underlying allergic component is necessary for adequate medical management 2.

Surgical Planning Considerations

• Reduction-rhinoplasty can cause breathing disturbances which are reported in 70% of all revision-rhinoplasty-patients, emphasizing the importance of proper technique and adequate cartilage support 7.
• The main risks of autogenous transplants are dislocation and resorption, which is why the surgeon's plan to use rib cartilage for adequate structural support is appropriate 7.
• Septoplasty demonstrates strong evidence for effectiveness, with up to 77% of patients achieving subjective improvement, but combined septorhinoplasty has different success metrics 1.

Recommendation for Resubmission

To obtain approval, the following must be submitted:

• Complete nasal endoscopy report with detailed findings of septal deviation, turbinate status, and nasal valve function 2
• CT scan of sinuses and nasal cavity with radiologist interpretation 2
• Standard 4-way photographic views (anterior-posterior, bilateral lateral, and base view) clearly showing external nasal deformity 1
• Confirmation of medical management compliance including specific medications, doses, duration, and documented treatment failure 1, 2

Once this documentation is provided, the case should meet medical necessity criteria for functional septorhinoplasty based on traumatic nasal deformity with septal deviation, nasal valve collapse, and failed conservative management 1.