Diagnosis: Deviated nasal septum; chronic sinusitis

Treatment: Vestibular Stenosis repair procedure (code 30465)

The insurer denied coverage for Vestibular Stenosis repair procedure (code 30465). The denial was reversed.

This patient is a female diagnosed with chronic sinusitis, and a deviated nasal septum. The patient was treated with antibiotics, and nasal sprays. The CT scan of the sinuses revealed the nasal septum was deviated to the right. There was a spur present. There was a mild to moderate mucosal thickening in the bilateral maxillary sinuses. The ostiomeatal complex was obstructed on the right side and the left side demonstrated infundibular stenosis.

The physical examination indicated the patient had a nasal vault that was narrow. The right nasal bone was depressed. There was alar narrowing and mild vault weakness. The septum was deviated. There was bleeding on the right. The operative indications included nasal congestion. The endoscopy examination revealed the inferior turbinate was 2+ bilaterally. The mucosa bilaterally had erythema. The provider noted the patient's bone was depressed on the right due to a fracture in the past. The patient was to be scheduled for an open reduction with treating the septum, a septoplasty, a turbinate reduction, and vestibular stenosis repair.

According to the referenced current medical literature, rhinoplasty and septoplasty may be performed to correct impaired breathing caused by structural defects in the nose, including to correct a deviated septum. The referenced peer-reviewed literature also notes that open structure rhinoplasty using spreader grafts, including autologous grafts, is effective in reconstruction of the internal nasal valve and preserving or improving nasal patency.

The patient had a history of a nasal fracture. On examination the patient had a depressed bone on the right and a narrow nasal vault with Alar narrowing and mid-vault weakness. These findings would support the requested vestibular stenosis repair. Therefore, the healthcare plan did not act reasonably and with sound medical judgment, and the best interest of the patient. The vestibular stenosis repair procedure is considered medically necessary for this patient.

Based on the above, the medical necessity for the Vestibular Stenosis repair procedure (code 30465) is substantiated. The insurer's denial is reversed.