Clinical UM Guideline



Subject: Septoplasty
Guideline #:  CG-SURG-18 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

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 septoplasy: 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 Allergy, Asthma and & Immunology. Available at: http://www.aaaai.org/home.aspx. Accessed on April 04, 2017.
  2. 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 04, 2017.
Index

Nasal Obstruction
Septal Deviation

History
Status Date Action
Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (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.