Anthem Blue Cross Connecticut CG-SURG-18 Septoplasty Form

This document addresses indications for septoplasty. This document may also be used to review the septoplasty component of procedures which combine both rhinoplasty and septoplasty (that is, septorhinoplasty). Medically necessary criteria for the rhinoplasty component of the combined procedure and relevant coding instructions can be found in ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck.

Note: Please see the following related documents for additional information:

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• SURG.00079 Nasal Valve Repair
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
• CG-SURG-87 Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

Clinical Indications

Medically Necessary:

Nasal septoplasty is considered medically necessary when the following criteria have been met:

1. An appropriate and reasonable trial of conservative management has been attempted and failed (including use of any of the following, either alone or in combination: topical nasal corticosteroids, decongestants, antibiotics, allergy evaluation and therapy, etc.); and
2. Either of the following conditions (criterion 1 or 2) are present:
   1. There is symptomatic septal deviation or deformity resulting in one or more of the following:
      1. There are distressing symptoms of nasal obstruction with documented absence of other causes of obstruction likely to be responsible for the symptoms (for example, nasal polyps, tumor, etc.); or
      2. There is persistent or recurrent epistaxis; or
      3. There is chronic or recurrent acute sinusitis; or
   2. There is an asymptomatic deformity that prevents surgical access to other intranasal or paranasal areas (for example, sinuses, turbinates).

Not Medically Necessary: 

Septoplasty is considered not medically necessary when the above criteria are not met and for all other indications.