My 22 year old son has a deviated septum, how? we don't know, it may be something he's had since birth. We received a predetermination from the insurance which states that surgery is not a medical necessity. Early in our lives we never had insurance so the constant nose bleeds and stuffiness were controlled with Kleenex, now that we have insurance they tell us if it were caused by an accident or injury or is therapeutic surgery or to correct a congenital defect it would be covered. Advice please.
Septoplasty Surgery. Advice When Insurance Company Says No?
Doctor Answers 2
If a patient has a deviated septum, it might take time but there is no reason why it shouldn't be covered by insurance
There are a number of factors insurance companies use to determine if a septoplasty is medically necessary. First is the exam and description by the doctor. Second is objective evidence that may be in the form of a CT scan or photo taken inside the nose with a special scope. Third, your doctor may need to document symptoms and treatment over a number of months. If that means repeated visits or notes from prior treating physicans, especially ENT or Allergist, that should suffice. It might take persistance though by your doctor's office.
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Unfortunately insurance companies can make their own rules. May be that is why they need to be regulated.
Remember their position when you renew your policy and may be you can find a better insurance company to spend your money on.
You can ask your insurance carrier for a specialist review. Your documentation is a letter of medical necessity from the ENT surgeon and your family physician.