A. a deviated septum causing continuous nasal obstruction on one or both sides of the nose;
[INFORMATIONAL NOTE: Assessment of a deviated septum and nasal obstruction is done best by direct examination (speculum exam or endoscopy) with an appropriate accompanying documented medical history of nasal obstruction. Plain films are not indicated in most instances; they do not help because the cartilaginous portion of a deviated septum is not easily visible. A CT scan usually is obtained for concurrent reasons, such as assessing sinus disease or evaluating head and/or facial trauma. While septal deviations are readily apparent on CT scans, obtaining a CT scan is not necessary in a patient in whom no other pathology is suspected (e.g., concomitant sinus disease.]

B. documented chronic or recurrent episodes of sinusitis on the same side as the septal deviation not alleviated or prevented by adequate medical management (i.e. appropriate antibiotics, antihistamines, topical/oral decongestants, and/or topical steroids);
[INFORMATIONAL NOTE: The diagnosis of sinusitis is based on a combination of clinical history with physical examination, nasal cytology, and/or imaging studies. Imaging studies may be required when the symptoms are vague, physical findings are equivocal, and there is poor response to the initial management. Standard radiographs may be used for detection of acute sinus infection, but they are insensitive, especially in ethmoid disease. Computed tomography is the preferred imaging technique for preoperative evaluation of the nose and paranasal sinuses secondary to obstruction of the ostiomeatal complex.]

C. recurrent epistaxis (3 or more episodes in the last 12 months) related to a septal deformity and not responsive to more conservative therapy such as nasal packing, cauterization, avoidance of medication affecting coagulation, and/or adding humidity to the environment; or

D. asymptomatic septal deviation that is obstructing the surgical field of a primary operation (e.g., ethmoidectomy, turbinectomy, nasal polypectomy, cauterization of a posterior bleeding vessel).

A. Detailed history and physical examination;
B. Medical records from treating physician(s) documenting a chronic nasal problem and/or recurrent epistaxis which has failed medical or more conservative management;
C. Diagnostic studies such as nasal endoscopy, facial x-rays, or CT scans as clinically indicated. (Refer to informational notes under statements I-A and I-B);

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Septoplasty

References:
1. Clinical Indicators Compendium: Septoplasty. 2012 American Academy of Otolaryngology - Head and Neck Surgery.

Available at: http: http://www.entnet.org/sites/default/files/Septoplasty-CI%20Updated%208-7-14_0.pdf (accessed 11/26/14)

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