A septoplasty is a surgical procedure designed to correct a deviated nasal septum—the cartilage and bone dividing the nasal cavity that has become off-center. When the septum is significantly shifted, it can lead to chronic breathing difficulties and other health issues. Medicare generally covers septoplasty, but coverage is strictly limited to instances where the procedure is medically necessary to restore or improve function. This means coverage is not automatic and depends entirely on the documented functional impairment caused by the deviation.
Medical Necessity Requirements for Coverage
Medicare Part B covers services determined to be medically reasonable and necessary for the diagnosis or treatment of illness or injury. This standard is the determinant for covering a septoplasty; any procedure performed solely for cosmetic reasons is excluded from coverage. For a septoplasty to be covered, the patient must demonstrate a significant functional impairment directly caused by the deviated septum that has not been resolved by conservative treatments.
One of the most common medical necessity criteria is continuous nasal airway obstruction severe enough to cause difficulty breathing or mouth breathing. The documentation must show that the patient has failed an adequate trial of conservative medical therapy, such as nasal steroid sprays, decongestants, or allergy treatments, typically lasting four to six weeks. A septoplasty may also be deemed necessary if the septal deviation causes recurrent, severe symptoms like chronic rhinosinusitis, documented by four or more episodes per year, or frequent nosebleeds (epistaxis).
Furthermore, Medicare may cover the surgery if the deviated septum obstructs the effective use of a Continuous Positive Airway Pressure (CPAP) machine for treating obstructive sleep apnea. In some cases, a septal deformity that does not cause symptoms itself but prevents the surgeon from accessing other intranasal areas to perform another medically necessary procedure, such as an ethmoidectomy, is also covered.
Costs and Financial Responsibility Under Medicare Part B
For a medically necessary septoplasty performed on an outpatient basis, coverage falls under Original Medicare Part B, which addresses physician services and outpatient care. The beneficiary must first meet the annual Part B deductible (\$257 in 2025). Once satisfied, Medicare pays 80% of the Medicare-approved amount for the procedure and related services, including the surgeon’s fee and the facility charge at an Ambulatory Surgical Center or hospital outpatient department.
The remaining 20% of the Medicare-approved amount is the patient’s coinsurance responsibility, which can represent a substantial out-of-pocket cost since there is no annual limit on this 20% under Original Medicare. If the procedure requires an inpatient hospital stay, the coverage would shift to Medicare Part A, requiring the patient to pay the Part A deductible, which is \$1,676 per benefit period in 2025. Most septoplasties are performed on an outpatient basis, making the Part B costs the primary financial concern for the patient.
Navigating Medicare Advantage and Supplemental Coverage
Beneficiaries can manage their financial exposure through either a Medicare Advantage Plan (Part C) or a Medicare Supplement Insurance (Medigap) policy. Medicare Advantage plans are offered by private insurance companies and must cover all the same medically necessary services as Original Medicare. The main difference is that Part C plans set their own patient cost-sharing, including specific copayments or coinsurance amounts for the septoplasty procedure that may differ from the standard 20% under Part B.
Part C plans often operate with provider networks, like Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which require patients to use in-network doctors and facilities to receive the lowest cost-sharing. These plans frequently require pre-authorization or prior approval for non-emergency surgeries like septoplasty, adding an administrative step before the procedure can be scheduled. Conversely, Medigap policies work alongside Original Medicare and are specifically designed to cover the financial “gaps” left by Part B.
A Medigap policy, such as Plan G or Plan N, will pay the 20% Part B coinsurance and may cover the Part B deductible, significantly reducing or eliminating the patient’s out-of-pocket costs for the approved septoplasty. Unlike Medicare Advantage, Medigap plans do not have provider networks and do not require pre-authorization, as they only pay costs for services already approved and paid for by Original Medicare. Choosing between Part C and Medigap depends on whether the patient prioritizes lower monthly premiums with managed care and varying copays or higher premiums for predictable, near-zero out-of-pocket costs and greater provider choice.
Required Documentation and Pre-Authorization Steps
The administrative process begins with the surgeon gathering comprehensive documentation to prove the medical necessity of the septoplasty. This evidence typically includes a detailed patient history of symptoms, the duration of nasal obstruction, and a record of failed conservative medical treatments. Objective testing, such as a nasal endoscopy or a CT scan, is often required to document the structural severity of the septal deviation.
While Original Medicare does not generally require pre-authorization for Part B services, the surgical facility or the Medicare Advantage plan may impose a prior approval process. For Part C plans, the provider must submit the clinical documentation to the plan to obtain approval before the surgery can proceed. Patients should confirm that all necessary documentation has been submitted and that pre-authorization has been secured to prevent unexpected denial of the claim.