Will Insurance Cover my Septoplasty And/or Rhinoplasty? I've Developed Sleep Apnea.

I sustained a trauma to my nose in 2005. My nose was pushed to the side of my face. The doctor cracked it back into place, but it is still misaligned and has a dent on the side. I had insurance then and still have insurance, but with a different carrier. I was diagnosed with moderate sleep apnea in 2009 and sleep with a cpap machine on high pressure. I was wondering if insurance is likely to cover septoplasty and/or rhinoplasty? My current insurance is crap and excludes sleep apnea treatment.

Doctor Answers 7

Sleep Apnea

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The first step in treatment resides in recognition of the symptoms and seeking appropriate consultation. Oral and maxillofacial surgeons offer consultation and treatment options.In addition to a detailed history, the doctors will assess the anatomic relationships in the maxillofacial region. With cephalometic (skull x-ray) analysis, the doctors can ascertain the level of obstruction. Sometimes a naso-pharyngeal exam is done with a flexible fiber-optic camera. To confirm the amount of cardiovascular compromise and decreased oxygenation levels, a sleep study may be recommended to monitor an individual overnight. Most major medical plans offer coverage for diagnosis and treatment.

Red Bank Dentist

Can insurance cover my septoplasty and rhinoplasty?

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Insurance policies vary depending on the diagnosis, timing of injury, and proposed treatment. If the reason is for sleep apnea, septoplasty may be covered; however rhinoplasty that is done for cosmetic reasons is not. 

Jose E. Barrera, MD, FACS
San Antonio Facial Plastic Surgeon
4.9 out of 5 stars 57 reviews

Septoplasty and functional rhinoplasty should be covered by your insurance if you had an accident.

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Dear David5859:

The trauma that you had to your nose in 2005 appears to have changed the shape of your nose.  If the accident also caused the change in your breathing, then certainly your insurance should participate in payment for the reconstructive surgery.

There is a difference between that and cosmetic surgery, which is improving what Nature gave you. Reconstructive surgery  is trying to restore your nose to reasonable form and function after an accident.

The fact you were diagnosed in 2009 with sleep apnea suggests that you have significant nasal blockage.  If you are using a CPAP, that is further proof that you have indeed airway obstruction, which is a functional and not a cosmetic issue. Therefore, health insurance benefits should apply.

My advice: before you have the surgery, consult with the insurance agent who sold you the policy. Or if your insurance is covered by your employer, speak with someone in Human Resources, and have them help you explain your condition to the insurance company. Thus, before the surgery you are comfortable about what will, and will not, be paid for. 

Your plastic surgeon should be willing to submit to the insurance carrier a letter of explanation about why you need to have the surgery to correct the accident damage.  The surgeon will also indicate what procedures are in planning and supply them with the five-digit CPT code number, allowing them to understand the exact nature of the operation. 

The bottom line: you must have all the ducks in a row before  surgery.  That’s the time to have any discussions with the insurance company, but it is always good to have someone else on your side such as your employer or the agent who sold you the policy. 

So remember, if all of these problems with:

  •    Appearance
  •    Breathing
  •    Sleep apnea

  are a result of the accident, it would seem to me that the policy should provide benefits to you.

Robert Kotler, MD, FACS
Facial Plastic Surgeon

Robert Kotler, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 90 reviews

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Septo/rhinoplasty for Treatment of Nasal Trauma & Sleep Apnea

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Insurance companies frequently pay for surgery to treat a broken nose and nasal surgery in patients with sleep apnea. You surgeon's office can help you get pro-operative authorization. However, it is extremely difficult to determine how much they will pay.

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Nasal surgery and sleep apnea

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If you have a significant deviated septum, then insurance should cover the surgery. "Cover" could mean they pay for 80% of the cost after you have paid your $2000 deductible for the year plus the 20% copay. If your external nose is severely deviated from injury it might also be covered; that is much harder to predict. An experieced rhinoplasty surgeon should have staff that can help you get a better idea about these out of pocket costs for insured patients like yourself.

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Rhinoplasty, Sleep apnea and Insurance

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I wish I ccould give youo the simple answer, but it depends on your insurance carrier.  Many will cover the allowed expense of a septorhinoplasty if it is the result of trauma.  Others will say the external nasal wwork is cosmetic and will only cover the septum.  Many doctors will not accept what insurance reimburses as the full cost.  I would see several plastic surgeons in consultation.  Once you have decided on one of them a pre-authorization can be obtained  and they caan check with yoyour insurance company to see what is covered.  Then you can determine your out of pocket expense.  Good luck

Rhinoplasty and sleep apnea

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A traumatic injury that caused a deviated fractured septum may very well be covered by insurance, but sleep apnea is usually unrelated to septal deviations.

Steven Wallach, MD
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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.