Can my insurance cover my Septorinoplasty?

Question

I recently broke my nose while playing soccer, resulting in a crooked nose. Despite a closed nasal reduction procedure done by my ENT, my nose is still not straight, and I experience some difficulties and uncomfortableness in my breathing. I'm considering septorhinoplasty for a more permanent solution for my crooked nose and breathing. I'd like to know if my insurance covers this procedure. Could you advise me on how to determine if my insurance plan will cover it? Thank you

Thomas Spalla, MD · Answer

Insurance is unbelievably challenging to navigate and the waters are VERY murky.
Your situation is very common, and it's unfortunate that insurance companies seek to deny this over and over again. Their position is that this is a cosmetic issue solely. I never understood the logic when it comes to a broken nose. If I broke my arm and it healed crooked, I would expect to get help with this through my insurance.

What you'll need to do is find a surgeon who has a team familiar with such situations. You'll need a consultation, and then the surgeon's team will need to file preauthorization paperwork through your insurance company - codes to designate the necessary procedures, codes that fit your diagnoses, and possibly office notes, imaging reports, and even pictures. This process can take weeks. It's usually rejected if codes for a rhinoplasty are used - despite that being what you need done.

Further resubmission is often required followed by a "peer-to-peer" discussion where your surgeon will have to take the time to call the company and try and convince their "expert" that you need this done. Despite all this, it's still not guaranteed this will work.

Your assistance in calling your insurance company can sometimes be helpful as well.

Document who you spoke to and when along with any advice or rejection received. This may come in handy when moving forward with further filings and complaints.

I wish you the best of luck. I've dealt with insurance companies over this exact issue for 14 years, and it's one aspect of the job every surgeon I've ever spoken with hates.

William Portuese, MD · Answer

The short answer to your question is you need to look at the specific exclusions on your insurance plan, such as cosmetic surgery. Your prospective rhinoplasty surgeon will need to see you in person and submit for medical necessity and pre-authorization with whatever medical insurance company that you have. You could also have In-network, or out of network benefits. You will also have to responsible to pay for the co-pays and deductibles.

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