When Septoplasty/Rhinoplasty Are BOTH Medically Necessary How Do You Get Coverage?

When you have your consultation with your board certified PS, they can help you get insurance coverage.

Your surgeon must obtain preauthorization and establish functional medical necessity for both parts. However, insurance companies now have wonderful rules that prohibit payment for two procedures through the same incision which effectively means that there will be no reimbursement for the lesser included procedure. Please know that, even if your doctor is out of network, the same rules apply so you should clarify your financial responsibility in advance. In some cases, I perform septolasty first to assess whether this improves breathing sufficiently and then make a decision as to the second element of the surgery. Insurance companies have long been on the warpath about anything remotely cosmetic on the face so also know that preauthorization is not a guarantee of payment.

Greetings, Shelli.

A crooked nose that does not breathe well is best managed by functional nasal reconstruction. Whether or not the insurance company pays for such depends on the report your surgeon submits. Typically, insurers do pay for such reconstructive surgery because it is not purely cosmetic. There is the poor breathing and there is the deformity on the outside. Probably both related; perhaps you had an injury when younger.

Here is my advice: consult an experienced nasal surgeon. Ask for his/her recommendation for surgery to repair your nose. Then ask the office manager to contact your insurer and ask if, based on the doctor's exam," benefits are available for this procedure?" The doctor will send a report to the insurer and it is wise to include photos so the insurance clerk understands the situation. The company is dutibound to tell you if that operation is a "covered benefit". Read your insurance policy benefit book to double check. 

Make sure to get everything in writing from the insurer and always get the name, title and phone number of whoever you speak with at the insurer. Also check with your insurance agent ( if an individual policy) or your company's HR department ( if insurance provided by your employer) so that  everything is in place.

You must do all the homework up front; the last thing you want to do is to find out , after surgery,  that the insurance company does not pay for that service. Be very dilligent.

Good luck.

-Robert Kotler, MD, FACS

 Author, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON