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.

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.

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.

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.

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

 

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!

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.

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 does not cover rhinoplasty.Insurance will cover functional obstruction and problems related to it.