Clinical UM Guideline
Subject: Septoplasty
Guideline #: CG-SURG-18 Publish Date: 04/07/2021
Status: Revised Last Review Date: 02/11/2021
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 either of 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 when the above criteria are not met and for all other indications including, but not limited to, 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.

When services may be Medically Necessary when criteria are met:

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

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a situation designated in the Clinical Indications section as not medically necessary.

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. Sinusitis can be acute; meaning the symptoms occur for less than 4 weeks, or it can be chronic which means symptoms last for longer than 12 weeks. The Centers for Disease Control and Prevention (CDC) estimates sinusitis affects more than 28.9 million adults in the United States.

Frequently these conditions respond to medical treatment such as antibiotics and steroid therapy. When medical management is not successful, a septoplasty may be 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.”

In a 2019 open, multicenter, pragmatic, randomized controlled trial in the Netherlands, van Egmond and colleagues reported on individuals who had nasal obstruction, a deviated septum, and an indication to have septoplasty. The participants were randomly assigned (1:1) to receive either septoplasty (n=102) with or without concurrent turbinate surgery or non-surgical treatment (n=101). The primary objective of the study was to assess the effectiveness of septoplasty when compared to nonsurgical treatment of nasal obstruction in adults using the self-reported Glasgow Health Status Inventory (GHSI). Secondary objective outcomes included nasal patency measured by peak nasal inspiratory flow (PNIF) and 4-phase rhinomanometry (4PR). Secondary subjective outcomes included the Nasal Obstruction Symptom Evaluation (NOSE) scale, sino-nasal outcome test-22 (SNOT-22), the three-level EuroQol, five dimensions (EQ-5D-3L), and Glasgow Benefit Inventory (GBI). Participants were included if there was a primary diagnosis of nasal obstruction as the main indication for septoplasty. Participants were excluded if the primary indication for septoplasty was based on concurrent complaints such as sleep disorders, headaches, or impairment of normal sinus drainage. Other exclusions included history of nasal septal surgery, untreated allergic rhinitis or allergic rhinitis unresponsive to medical treatment, septal perforation, or if the septoplasty was being done as part of a cosmetic rhinoplasty or in participants with a cleft lip or palate. For those in the non-surgical treatment group, there was no pre-specified treatment regimen. The decision between watchful waiting and medical treatment (usually local corticosteroids) was made on an individual basis. The median duration of nasal obstruction before trial entry was 7 years, and most participants (79% in the septoplasty group; 86% in the non-surgical management group) had received previous treatment for nasal obstruction. Primary analysis was done at 12 months on 94 participants who had septoplasty and 95 participants who had non-surgical treatment. In the septoplasty group, GHSI mean score was 72.2, NOSE score was 67.5, SNOT-22 score was 76.8, EQ-5D-3L utility score was 0.89, EQ-5D-3L VAS score was 74.0, PNIF before decongestion was 124.3, PNIF after decongestion was 133.0. In the non-surgical group, GHSI mean score was 63.9, NOSE score was 49.6, SNOT-22 score was 67.0, EQ-5D-3L utility score was 0.87, EQ-5D-3L VAS score was 74.9, PNIF before decongestion was 95.0, PNIF after decongestion was 109.7. Overall 4PR differences were small and less consistent than were the results from PNIF. For the participants in the non-surgical treatment group, if complaints persisted during the 24 months of follow-up, they were able to cross-over to the surgical group and monitored as planned. A total of 30% of the participants did cross over. Due to the nature of the trial (surgery versus non-surgical arm), masking was not possible. Participants were followed for a total of 24 months and benefits (both objective and subjective) continued. The authors conclude that the trial:

Shows that many patients, despite medical treatment, continue to live with nasal obstruction for years before being referred to the ear, nose, and throat surgeon. In these patients, septoplasty offered considerable subjective and objective benefits compared with non-surgical management, which were sustained up to 24 months of follow-up.

A 2020 Clinical Practice Guideline by the American Academy of Otolaryngology/Head and Neck Surgery for nosebleed (epistaxis) notes that septoplasty can be done in individuals with recurrent nosebleeds and septal deviation stating “control of bleeding likely from some combination of improved nasal airflow, interruption of mucosal vasculature, and/or more effective packing.”

Clinical trials are in progress to assess the effect of conservative management versus septoplasty for septal deviation with nasal obstruction.

Definitions

Epistaxis: Nose bleeding.

Rhinoseptoplasty: A surgical procedure, also referred to as a septorhinoplasty, performed on the nose and the nasal septum (cartilage and bony structure that separates the two nostrils).

Septoplasty: A surgical procedure intended to repair the nasal septum.

Sinusitis: Inflammation of the sinuses.

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.
  5. van Egmond MMHT, Rovers MM, Hannink G, et al. Septoplasty with or without concurrent turbinate surgery versus non-surgical management for nasal obstruction in adults with a deviated septum: a pragmatic, randomised controlled trial. Lancet. 2019; 394(10195):314-321.

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. American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS). Clinical Practice Guideline: Nosebleed (Epistaxis). 2020; 162(1S):S1-S38. Available at: https://journals.sagepub.com/doi/pdf/10.1177/0194599819890327. Accessed on October 22, 2020.
  3. 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: https://www.enthealth.org/conditions/deviated-septum/. Accessed on October 22, 2020.
  2. Centers for Disease Control and Prevention. Chronic Sinusitis. February 21, 2020. Available at: https://www.cdc.gov/nchs/fastats/sinuses.htm. Accessed on October 22, 2020.
Index

Nasal Obstruction
Septal Deviation

History

Status

Date

Action

Revised

02/11/2021

Medical Policy & Technology Assessment Committee (MPTAC) review. Administrative edits to Clinical Indications. Updated Discussion/General Information and References sections. Reformatted Coding section.

Reviewed

02/20/2020

MPTAC review. Added Definitions section. Updated Discussion/General Information and References sections.

Reviewed

3/21/2019

MPTAC review. Updated References section.

Reviewed

05/03/2018

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.

 


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