Clinical UM Guideline

 

Subject: Septoplasty
Guideline #:  CG-SURG-18 Publish Date:    06/06/2018
Status: Reviewed Last Review Date:    05/03/2018

Description

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, rhinoseptoplasty). 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:

Clinical Indications

Medically Necessary:

Nasal septoplasty is considered medically necessary for the following conditions when an appropriate and reasonable trial of conservative management (which might include use of topical nasal corticosteroids, decongestants, antibiotics, allergy evaluation and therapy, etc.) has failed.

Not Medically Necessary: 

Septoplasty is considered not medically necessary for any of the following:

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

30520

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

30620

Septal or other intranasal dermatoplasty (does not include obtaining graft)

 

 

ICD-10 Procedure

 

09BM0ZZ

Excision of nasal septum, open approach

09BM3ZZ

Excision of nasal septum, percutaneous approach

09BM4ZZ

Excision of nasal septum, percutaneous endoscopic approach

09SM0ZZ

Reposition nasal septum, open approach

09SM4ZZ

Reposition nasal septum, percutaneous endoscopic approach

09TM0ZZ

Resection of nasal septum, open approach

09TM4ZZ

Resection of nasal septum, percutaneous endoscopic approach

 

 

ICD-10 Diagnosis

 

J32.0-J32.9

Chronic sinusitis

J34.0

Abscess, furuncle and carbuncle of nose

J34.1

Cyst and mucocele of nose and nasal sinus

J34.2

Deviated nasal septum

J34.81-J34.89

Other specified disorders of nose and nasal sinuses

Q67.4

Other congenital deformities of skull, face and jaw

R04.0

Epistaxis

S02.2XXA-S02.2XXS

Fracture of nasal bones

Discussion/General Information

Septoplasty is a surgical procedure performed to correct airway obstruction related to the nasal septum. These obstructions can be caused by structural deformity, disease or trauma.

Deviation of the nasal septum is a common cause for nasal obstruction. Septal deviation occurs when the septum, which divides the two sides of the nasal cavity, is displaced from a straight vertical alignment causing blockage of airflow through one or both sides of the nose. The change in airflow can contribute to mucosal drying leading to epistaxis and sinusitis. Frequently these complications respond to medical treatment such as antibiotic and steroid therapy. When medical management is not successful, a septoplasty is considered. This surgical procedure, usually performed under local or general anesthesia, corrects nasal septum defects or deformities by alteration, splinting, or partial removal of obstructing structures. Septoplasty is usually done to improve breathing, but it also may be performed to assist in the management of polyps, tumors or epistaxis.

Moore and Eccles (2011) reported on a review of 14 articles in which nasal airflow was measured before and after septoplasty due to nasal obstruction because of septal deviation. The articles were limited to those with surgery on the nasal septum (including septoplasty, submucous resection and septal deviation corrective surgery) and articles with different forms of objective measurement of nasal airflow including rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow. The 14 articles included 536 participants and all showed “objective evidence that septal surgery improves nasal patency.”

References

Peer Reviewed Publications:

  1. Lawrence R. Pediatric septoplasty: a review of the literature. Int J Pediatr Otorhinolaryngol. 2012; 76(8):1078-1081.
  2. Moore M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clinical Otolaryngology, 2011; 36(2):106-113.
  3. Sedaghat AR, Busaba NY, Cunningham MJ, Kieff DA. Clinical assessment is an accurate predictor of which patients will need septoplasty. Laryngoscope. 2013; 123(1):48-52.
  4. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004; 130(3):283-290.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS). Clinical Consensus Statement: septoplasty with or without inferior turbinate reduction. Otolaryngol Head Neck Surg. 2015; 153(5):708-720.
  2. Cummings CW, Flint P, Haughey B, et al. Otolaryngology: Head & Neck Surgery, 4th ed. Philadelphia: Mosby. 2005.
Websites for Additional Information
  1. American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS). Fact sheet: deviated septum. Available at: http://www.entnet.org/?q=node/1406. Accessed on April 12, 2018.
Index

 

Nasal Obstruction
Septal Deviation

 

History

Status

Date

Action

Reviewed

05/03/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Websites section.

Reviewed

05/04/2017

MPTAC review.

Reviewed

05/05/2016

MPTAC review. Updated Description/Scope, Background/Overview, and References sections. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review.

Reviewed

05/15/2014

MPTAC review. Updated Description and Coding sections.

Reviewed

08/08/2013

MPTAC review. Updated References.

Revised

08/09/2012

MPTAC review. Updated Discussion/General Information and References. Clarification to Clinical Indications.

Reviewed

11/17/2011

MPTAC review. Updated Discussion/General Information and References.

Reviewed

11/18/2010

MPTAC review. Updated References.

Reviewed

02/25/2010

MPTAC review. Updated References.

Reviewed

02/26/2009

MPTAC review. Updated References and Web Sites. Removed Place of Service.

Reviewed

02/21/2008

MPTAC review. References and Coding updated.

Reviewed

03/08/2007

MPTAC review. References and Coding updated.

New

03/23/2006

MPTAC initial document development.