A deviated septum occurs when the thin wall of cartilage and bone, known as the nasal septum, is significantly displaced to one side of the nose. This structural abnormality can obstruct one or both nasal passages, leading to difficulty breathing, chronic sinus issues, and other functional impairments. The necessary procedure to correct this is called septoplasty, or septal reconstruction, which involves straightening and repositioning the septum to improve airflow. Medicare may cover this surgery, but coverage is strictly conditional on specific criteria, primarily focusing on the medical necessity of the procedure.
Defining Medical Necessity for Septoplasty
Medicare’s coverage determination for septoplasty centers on whether the procedure is deemed medically necessary to correct a functional impairment. The Centers for Medicare & Medicaid Services (CMS) guidelines explicitly exclude coverage for cosmetic surgery, which is defined as any procedure solely directed at improving appearance. Septoplasty is a reconstructive procedure meant to restore or improve physiological function, and any resulting improvement in nasal appearance is considered incidental.
For a septoplasty to qualify as medically necessary, patients must present with documented symptoms. These symptoms often include persistent nasal airway obstruction that does not respond to conservative medical management, such as topical nasal corticosteroids or decongestants, typically after a trial period of at least six weeks. Recurrent episodes of sinusitis, often defined as four or more per year, that are secondary to the septal deviation also serve as justification.
A septoplasty may also be considered medically necessary if the deviated septum interferes with the effective use of a Continuous Positive Airway Pressure (CPAP) machine. The procedure is covered if the deviation is blocking access required for a surgeon to perform other medically necessary procedures, such as complex sinus surgery. Physicians must use specific diagnostic codes, known as ICD-10 codes, to document the functional impairment caused by the deviated septum, providing the justification for the claim.
Medicare Coverage Mechanisms
Septoplasty, when determined to be medically necessary, is primarily covered under Medicare Part B for physician services and outpatient care. Part B covers the services of the surgeon, the anesthesiologist, and the facility fees if the procedure is performed on an outpatient basis. Most septoplasties are minor surgeries performed in an outpatient setting, such as a hospital outpatient department or an Ambulatory Surgical Center (ASC).
The facility and professional services related to the septoplasty are billed using specific procedural codes, known as CPT codes, with CPT code 30520 being the standard code for septoplasty. When performed in an ASC, the facility and professional components are reimbursed separately based on the Medicare-approved amount.
Medicare Part A, the Hospital Insurance component, may cover the procedure only in the rare instance that the septoplasty requires an inpatient hospital stay due to surgical complexity or severe health issues requiring continuous monitoring. For beneficiaries enrolled in a Medicare Advantage Plan (Part C), the plan must cover all benefits provided by Original Medicare (Parts A and B). However, these private plans may require beneficiaries to use specific in-network providers or obtain prior authorization before the surgery.
Beneficiary Financial Responsibility
Even with Medicare coverage established for a medically necessary septoplasty, the beneficiary is responsible for a portion of the costs under Original Medicare. This liability begins with the annual Part B deductible, which the patient must meet before Medicare begins payment. After the deductible is satisfied, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for the physician services and the outpatient facility charges.
The remaining 80% of the cost is paid by Medicare directly to the provider. If the septoplasty is performed in an ASC, the patient’s coinsurance applies to the separate fees for the surgeon and the facility.
The total out-of-pocket cost can increase if the surgeon does not agree to “accept assignment,” meaning they have not agreed to accept the Medicare-approved amount as payment in full. In this situation, the provider can charge the beneficiary up to 15% more than the Medicare-approved amount; these are called “excess charges.” Beneficiaries who have a Medigap (Medicare Supplement Insurance) policy may have their financial burden reduced, as these plans are designed to help cover the Part A and B deductibles and coinsurance payments.