Rhinoplasty surgery, in the purest sense of the term, implies changes to the external or visible parts of the nose. Since the appearance of the nose does not necessarily affect how it functions, your insurance will not cover any of the rhinoplasty procedure if the goal is to achieve an improved looking nose. For instance, your insurance will deny coverage if your primary reason for surgery is improving a nose that is unattractive, too large or crooked.
But there are circumstances where insurance will provide coverage of a nasal procedure. Notice that I did not use the term rhinoplasty. As soon as you use that term, you are talking about changes to the outside of the nose which we know is not covered…unless the source of the problem is from a birth defect, traumatic injury, or from tumor removal. To define those further, birth defect usually means cleft lip and palate or some other craniofacial deformity where the nose has not developed normally. Traumatic injury means a documented history of nasal fracture, that is relatively recent (not 20 years ago or when you were a child) and there are medical records to substantiate that it actually happened. Tumor excision almost always means some type of skin cancer where a portion of the skin on the nose has been removed All of these external nose needs will constitute a reconstructive rhinoplasty procedure and there is not usually battle to get it approved. (most of the time)
Your insurance will not only cover for these reconstructive issues but they will also cover for breathing difficulties of the nose. A deviated septum is the classic case but there are other internal structures of the nose that can be obstructive, most notably the turbinate bones. Difficulty breathing can also cause headaches and contribute to sleep apnea. All of these are medical issues because they dysfunctional. Many times, the physician’s examination alone is sufficient to provide adequate documentation but other tests may eventually be required including nasometry, CT scans, or sleep studies. One key area that your medical insurance looks for is…what non-surgical treatments have been tried ( and failed) to prove that surgery is necessay. (and the last resort) This usually means a trial course of steroids or other nasal swelling treatment strategies.
Documentation is key for your insurance company to consider that such symptoms exist. Regardless of whether the medical necessity reason is a structural problem due to a birth defect or trauma or a long-standing breathing problem, a pre-determination letter must first be sent from your plastic surgeon. One must then wait until you receive a written response from the insurance company before ever proceeding to surgery. If you do not see it in writing, do not assume that it is going to be covered.
Do not let the urgency of your or your surgeon’s schedule override written confirmation of medical coverage. This is a common mistake. It is much better to know the financial facts up front (and then pay if you have to) than try and sort it out later when you are receiving bills and late notices from a variety of providers because it has been denied due to a lack of the required pre-determination. Remember, once you have it done without a pre-determination, the insurance company is not really under any obligation to pay after the fact. (even if it would have been initially qualified) Paying medical charges that are accrued at the rate of insurance billings are a lot higher than those charged for on a cosmetic fee basis. Let the insurance and pre-determination process run its course…or otherwise you may find yourself really paying through the nose.
Dr. Barry Eppley
Indianapolis Indiana