When both Septoplasty/Rhinoplasty are BOTH medically necessary how do u get coverage from your insurance? My ENT says due to the fact that the bone in my nose is crooked and blocking my breathing as well as the exterior end of my nose is also crooked and blocks my breathing, I would need both at the same time to correct my breathing function. Trying to only do Septoplasty will not correct my problem?
When Septoplasty/Rhinoplasty Are BOTH Medically Necessary How Do You Get Coverage?
Doctor Answers (9)
Insurance Coverage for Septorhinoplasty to Correct Breathing
The staff in your surgeon's office can help you contact your insurance company to explain your problem and the proposed surgery so you can get pre-operative authorization. Many policies do cover operations to improve nasal breathing, but many times it is difficult to get the company to tell you what they will pay.
Insurance coverage for rhinoplasty
Simply put, insurances cover only medically necessary procedures, and all cosmetic surgery is an exclusion from coverage. There is a procedure code for rhinoplasty, and if a patient calls his/ her insurance and simply asks whether rhinoplasty surgery is a covered servce, the answer most likely would be "yes, if it is deemed medically necessary by your doctor". In reality, medically necessary rhinoplasties are few and far in between: correction of congenital deformities, severe nasal trauma with nasal collapse, nasal deformities related to a disease (cancer, etc). Septoplasty, however, is almost always is a covered service, since it is aimed at improvement of nasal obstruction and almost never changes the appearance of the nose. So, for most patients with nasoseptal problems, who want cosmetic and functional improvement, rhinoplasty would be an out of pocket expense, whereas septoplasty component should be covered.
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A Crooked and Blocked Nose Usually Needs Septoplasty + Rhinoplasty
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.
-Robert Kotler, MD, FACS
Author, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON
Medically necessary rhinoplasty
This is a common complaint and frustration for many patients and their physicians. While there may be no way to adequately fix your breathing without doing some rhinoplasty work insurance companies will still not pay. There is nothing your physician can do to "convince them of the necessity" and even getting preauthorization means nothing. Any claim submitted with rhinoplasty codes in it is a red flag for them. They will request the records and simply not pay. They are for profit entities and not in the business of paying for this type of surgery.
IF your surgeon has deemed that both are medical necessary for functional reasons, he/she will usually obtain a preauthorization with your insurance company. Insurance companies will not cover any cosmetic changes or improvements to your nose. This process takes some time, so be patient!
Insurance and rhinoplasty
Insurance does not cover rhinoplasty.Insurance will cover functional obstruction and problems related to it.
Insurance coverage for septo-rhinoplasty
Although most insurance companies will cover correction of functional breathing problems of the nose and reconstruction after injury, the exact details of that coverage varies. Often their is a "gray area" for the insurance of what is reconstructive and what is cosmetic. Before your procedure, your surgeon will get preauthorization from your insurance company. This will list exactly what will and won't be covered. It is not unusual in rhinoplasty surgery for insurance to pay a portion and the patient to pay the rest to achieve the desired functional and cosmetic results.
What does insurance cover in nasal surgery?
This is a common question. Insurance companies generally cover procedures that are medically necessary. For nasal surgery this includes problems related to breathing. A deviated septum and enlarged turbinates can lead to difficulty breathing (obstruction of nasal airway) and thus are usually covered. If the nose is severely crooked, or if there is collapse of nasal valves (cartilage support), these can also be covered. Insurance plans will not pay for improvement in the appearance of the nose. Sometimes the outside cartilages are mis-shapen which can make a nose look uneven or crooked. This is not generally covered. Most insurance plans will cover the repair of a broken (fractured) nose at the time of injury, but some will not pay for correction of a previously injured nose. The best way to tell is to have the surgeon send for preauthorization from the insurance company if possible.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.