A deviated septum occurs when the thin wall of cartilage and bone separating the nostrils is displaced. This misalignment can restrict airflow, leading to breathing difficulties and other health issues. Septoplasty is a surgical procedure to correct this structural issue, aiming to straighten the septum and improve nasal breathing.
When Medicare Covers Septoplasty
Medicare Part B covers septoplasty when it is medically necessary to treat a health condition, not for cosmetic enhancement. Medical necessity is established when a deviated septum causes functional impairments like severe nasal obstruction, chronic sinusitis unresponsive to other treatments, or recurrent nosebleeds. These symptoms must be directly attributable to the deviated septum.
Coverage requires documentation that conservative treatments, such as nasal sprays or decongestants, have been tried and failed. Diagnostic tools like nasal endoscopy or CT scans help confirm the structural issue. The CPT code commonly used for septoplasty is 30520.
The procedure must be performed by a qualified surgeon in a Medicare-approved facility. Medicare does not cover septoplasty if its sole purpose is to improve aesthetic appearance.
Your Financial Responsibility
Even with Medicare coverage, beneficiaries typically have out-of-pocket costs. Under Original Medicare Part B, an annual deductible applies. After meeting this, individuals are responsible for a 20% coinsurance for physician services and outpatient facility fees. There is no annual limit on this 20% coinsurance under Original Medicare.
Septoplasty is usually an outpatient procedure. If an inpatient hospital stay is medically necessary, Medicare Part A costs, including a deductible, would apply.
Medicare Advantage (Part C) plans may have different cost-sharing structures and network restrictions, but must cover at least the same services as Original Medicare. Many beneficiaries use Medigap plans to help cover these out-of-pocket costs, such as deductibles and coinsurance.
The Pre-Approval Process
The treating physician initiates the pre-approval process by documenting the medical necessity of septoplasty. This includes detailed medical records, a history of symptoms, diagnostic test results like CT scans or nasal endoscopy, and notes on failed conservative treatments.
Some Medicare Advantage plans or contractors may require prior authorization before the procedure. This involves submitting medical documentation for review to ensure the proposed surgery meets Medicare’s coverage criteria.
A medical necessity review assesses if clinical evidence supports surgical intervention for a functional impairment. A clear and complete medical record is paramount for a smooth pre-approval process.
What if Coverage is Denied?
If Medicare denies coverage for septoplasty, beneficiaries have the right to appeal. Understanding the specific reason for denial is the first step. The initial appeal is a redetermination by Medicare.
If unsuccessful, the next level is reconsideration by a Qualified Independent Contractor (QIC). Further appeals can proceed to a hearing before an Administrative Law Judge (ALJ), then review by the Medicare Appeals Council (MAC), and finally judicial review in federal court.
For a successful appeal, gather additional medical evidence, such as new diagnostic results or physician letters. Resources like the State Health Insurance Assistance Program (SHIP) can provide free assistance throughout the appeals process.