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

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