National Medical Policy

Transcription

Posted: May 12, 2010
National Medical Policy
Subject:
Septoplasty, Turbinoplasty and Rhinoplasty
Policy Number:
NMP488
Effective Date*: March 2005
Updated:
January 2007, April 2008, May 2008, May
2010
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
Current Policy Statement (Update May 2010 – A Medline search failed t reveal
any studies that would cause Health Net, Inc. to change its current position)
Health Net, Inc. considers septoplasty (submucous resection), and associated middle
and inferior turbinate surgery with obstructive symptoms medically necessary to
correct internal deformities of the nose when any of the following is met:
1. To correct a deviated septum that produces chronic nasal obstruction and results
in significant medical disabilities from recurrent purulent sinusitis (more than 3
episodes per year), and both of the following:
a.
Must have radiologic evidence by CT scan of unremitting chronic or
recurrent sinusitis (e.g., clouding of sinuses, opacification of a sinus, airfluid levels or mucosal thickening with significant narrowing or obstruction
of the osteomeatal complexes); and
b.
Conservative therapy for a period of at least 3 months has failed to
alleviate or prevent episodes of sinusitis, including any of the following:
•
•
•
2.
Appropriate antibiotics; and
Nasal sprays, decongestants, antihistamines and/or topical
intranasal steroids; and
Specific documented attempts to discontinue nasal irritants,
including smoking, occupational exposure, drugs, and inadequate
humidification.
Recurrent epistaxis related to a septal deformity (4 or more significant episodes
per year) when conservative treatment measures have failed, such as avoidance
of medications affecting coagulation, adding humidity to the environment, and
cauterization; or
Septoplasty, Turbinoplasty and Rhinoplasty May 10
1
3.
Nasal septum trauma/perforation (within the past 18 months) that resulted in
new and significant functional abnormalities; or
4.
Need for reconstruction after the removal of a benign or malignant tumor, or
surgical removal of part of a structurally significant part of the nasal septum; or
5.
When done in association with congenital malformations (e.g., cleft lip and/or
palate or any craniofacial deformity associated with severe, documented
functional impairment); or
6.
Deviation is causing difficulty tolerating nasal continuous positive airway
pressure (CPAP) used to treat documented obstructive sleep apnea, and is
refractory to medical management; or
7.
Treatment of atypical, unilateral facial pain (Sluder’s Syndrome) caused by
septal contact points diagnosed by spray anesthesia of the nasal mucosa; or
8.
Documentation that obstructed nasal breathing is due to septal deformity:
a. Documentation of 75% obstruction, or
b. Documentation of 50% obstruction with continued symptoms despite
use of intranasal steroids for 6 weeks.
Note: We consider laser-assisted septoplasty and radiofrequency volumetric tissue
reduction (RFVTR, Somnoplasty) of nasal turbinates (turbinate coblation) medically
necessary as the turbinate mucosa can be measurably and reproducibly corrected
using these tools instead of a knife.
Contraindications to performing septoplasty include, but are not limited to:
1.
Large septal perforation;
2.
Cocaine abuse;
3.
Wegener granulomatosis;
4.
Malignant lymphomas or monoclonal T- or B-cell proliferations.
We consider rhinoplasty not medically necessary because it is a cosmetic surgical
procedure to shape the external contour of the nose (e.g., to correct the appearance
of a bulbous tip, an obvious bump or hook, or flared nostrils, etc.) However,
reconstructive rhinoplasty may be considered medically necessary to correct
deformities for functional improvement in any of the following explicit situations:
1. Birth defects, e.g., congenital cleft lip and/or palate, and any other congenital
craniofacial deformity, when associated with severe functional impairment
2. Significant, documented nasal trauma with distortion within the 3 months prior to
surgery that significantly compromises the nasal airway and can only be
corrected by combined septo-rhinoplasty as opposed to delayed open reduction
of nasal and septal fracture, (CPT 21335).
2
3. Choanal atresia
4. Cancer
5. Septal infection with saddle deformity
6. When there is documentation that obstructed nasal breathing due to septal
deformity is not amenable alone to septoplasty due to significant loss of
structural integrity of the septum by external nasal traumatic deformity.
7. To correct chronic non-septal nasal airway obstruction from vestibular stenosis
(collapsed internal valves and/or nasal bone distortion significantly compromising
the nasal airways) due to trauma, disease, or congenital defect, when all of the
following are met:
•
Nasal airway obstruction is causing significant symptoms (e.g., chronic
rhinosinusitis, difficulty breathing); and
•
Photos demonstrate clinically significant external nasal deformity; and
•
There is an average 50% or greater obstruction of nares (e.g., 50%
obstruction of both nares, or 75% obstruction of one nare and 25%
obstruction of other nare, or 100% obstruction of one nare), documented by
endoscopy and/or appropriate imaging modality when necessary; and
•
Obstructive symptoms persist despite conservative management for three
months or greater, which includes, where appropriate, nasal steroids or
immunotherapy; and
•
Airway obstruction will not respond to septoplasty and turbinectomy alone.
Note: Documentation of these criteria should include:
Results of nasal endoscopy, CT or other appropriate imaging modality
documenting degree of nasal obstruction; and
If there is an external nasal deformity, preoperative photographs
showing the standard 4-way view - base of nose, frontal view and
right and left lateral views; and
Relevant history of accidental or surgical trauma, congenital defect, or
disease (e.g., choanal atresia, nasal malignancy, abscess, septal
infection with saddle deformity, or congenital deformity); and
Documentation of duration and degree of symptoms related to nasal
obstruction, such as chronic rhinosinusitis, mouth breathing, etc.; and
Documentation of results of conservative management of symptoms
Note: Rhinoplasty is considered not medically necessary either alone or as an
integral part of a septoplasty when performed solely for the purposes of changing
appearance or in the primary treatment of obstructive sleep apnea, either performed
3
alone or routinely as part of another procedure such as uvulopalatopharyngo-plasty
(UPPP).
Codes Related To This Policy
ICD-9 Codes
090.5
470
473.0 - 473.9
478.0
478.1
738.0
748.0
748.1
749.0 - 749.04
749.20-749.25
754.0
780.57
784.7
802.0
802.1
CPT Codes
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
HCPCS Codes
Other late congenital syphilis, symptomatic
Deviated nasal septum (deflected nasal septum, acquired)
Chronic sinusitis
Hypertrophy of nasal turbinates
Other diseases of nasal cavity and sinuses
Acquired deformity of nose
Choanal atresia
Other congenital anomalies of nose
Cleft palate
Cleft palate with cleft lip
Certain congenital musculoskeletal deformities: of skull, face, and
jaw
Unspecified sleep apnea
Epistaxis
Fracture of nasal bones, closed
Fracture of nasal bones, open
Rhinoplasty primary; lateral and alar cartilages and/or elevation
of nasal tip
Rhinoplasty, primary; complete, external parts including bony
pyramid, lateral and alar cartilages, and/or elevation of nasal tip
Rhinoplasty, primary; including major septal repair
Rhinoplasty, secondary; minor revision (small amount of nasal tip
work)
Rhinoplasty, secondary intermediate revision (bony work with
ostomies
Rhinoplasty, secondary major revision (nasal tip work and
osteotomies)
Rhinoplasty for nasal deformity secondary to congenital cleft lip
and/or palate including columellar lengthening; tip only
Rhinoplasty for nasal deformity secondary to congenital cleft lip
and/or palate including columellar lengthening; tip, septum,
osteotomies
Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral
nasal wall reconstruction)
Septoplasty or submucous resection, with or without cartilage
scoring, contouring or replacement with graft
No specific codes
Scientific Rationale – Update April 2008
Septoplasty
(2000) The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) states: “Septoplasty or submuccous resection, with or without cartilage
scoring, contouring or replacement with graft is indicated, with nasal airway
4
obstruction or difficult nasal breathing causing any of the following: mouth
breathing; snoring, sleep apnea, or recurrent sinus infections”. This is listed as one
of the clinical indicators for septoplasty. Per the AAO-HNS the ‘Clinical Indicators for
Otolaryngology-Head and Neck Surgery’ are guidelines only. In no sense do they
represent a standard of care. The applicability of an indicator for a procedure, and/or
of the process or outcome criteria, must be determined by the responsible physician
in light of all the circumstances presented by the individual patient. Adherence to
these guidelines will not ensure successful treatment in every situation.
A deviated septum may cause one or more of the following:
•
Blockage of one or both nostrils; or
•
Nasal congestion, sometimes one-sided; or
•
Frequent nosebleeds; or
•
Frequent sinus infections; or
•
At times, facial pain, headaches, postnasal drip; or
•
Noisy breathing during sleep (in infants and young children).
(2007) Per the Institute for Clinical Systems Improvement (ICSI), septoplasty is
performed to straighten a deviated nasal septum, a cause of substantial nasal
obstruction. This procedure has a very high rate of success in improving the nasal
airway if the nasal septal deviation is the major etiology of the nasal obstruction.
Septoplasty may be considered medically necessary when there is documentation
that obstructed nasal breathing due to septal deformity or deviation is causing
difficulty tolerating nasal continuous positive airway pressure (CPAP) and it is
refractory to medical management. Septoplasty for obstructive sleep apnea may be
considered medically necessary when the medical criteria for septoplasty are met.
Sinusitis
Sinusitis represents one of the most common disorders in which antibiotic treatment
is given to the adult population, including cases of acute sinusitis, which is most
often initially viral.
The emergence of bacteria highly resistant to broad-spectrum antibiotics has forced
a modification regarding the treatment of upper respiratory infections. Antibiotics
should not be prescribed unless a bacterial infection is certain. The patient should be
educated about the rationale for this. Most cases of sinusitis would most likely
resolve with or without medical treatment. Sinusitis is usually treated, however, to
avoid potential complications and hasten recovery. The proximity of the paranasal
sinuses to the orbits and brain potentially allows infection to spread to these
locations.
(2001) Per the American Academy of Pediatrics, clinical practice guidelines for the
management of acute bacterial rhinosinusitis in children were published. Changes in
the antibiotic susceptibility patterns for the common pathogens causing both acute
and chronic rhinosinusitis warrant a re-evaluation and update. However, they note
5
that there are still insufficient data in the literature to develop evidence-based clinical
guidelines.
The Academy of Pediatrics Clinical Practice Guideline on the ‘Management of
Sinusitis’ for the diagnosis and treatment of acute bacterial sinusitis in children
notes that areas for future research include the following:
Determine the optimal duration of antimicrobial therapy for children
with acute bacterial sinusitis.
Determine the causes and treatment of subacute and recurrent acute
bacterial sinusitis.
Determine the efficacy of prophylaxis with antimicrobials to prevent
recurrent acute bacterial sinusitis.
Performance of prospective, randomized, clinical trials, to determine
an outcome of treatment with antibiotics and adjuvant therapies
(mucolytics, antibiotics, decongestants, antihistamines, etc) in patients
with acute bacterial sinusitis.
Determine the role of complementary and alternative medicine
strategies in patients with acute bacterial sinusitis by performing
systematic, prospective, randomized clinical trials.
Assess the effect of the pneumococcal conjugate vaccine on the
epidemiology of acute bacterial sinusitis.
Develop new bacterial and viral vaccines to reduce the incidence of
acute bacterial sinusitis.
(2006) There is an ongoing ClinicalTrials.gov Identifier: NCT00132275 to determine
the effectiveness of antibiotic treatment of children diagnosed to have acute sinusitis
on clinical grounds alone without the performance of sinus images and to evaluate
the response to antibiotic therapy or placebo. The estimated study completion date
was scheduled for September 2007, but this Clinical Trial has not been completed at
this time. There are also a number of other similar ongoing clinical trials.
Scientific Rationale - Initial
Nasal obstruction is one of the most common problems bringing a patient into a
physician's office, and septal deviation is a frequent structural etiology. There are
many potential causes for nasal obstruction. Blockage may occur when the lining of
the nose swells, or when there is a deformity of the cartilaginous or bony structures
that make up the framework of the nose. The two major components of the nasal
passages are the septum and the turbinates. The nasal septum is the part of the
nose that divides the right nasal cavity from the left nasal cavity and generally lies
directly in the center of the nose. In the inside of each nostril there are bony
projections called turbinates. Turbinates increase the surface area of the inside of the
nose aiding its air-filtering functions. There are three turbinates (inferior, middle, and
superior) on each side of the nose. The turbinates are lined with the nasal mucous
membranes which can shrink and swell dramatically to regulate nasal air resistance,
humidify the air and collect airborne particles on its surface to clean the air.
Septoplasty is an operation that corrects any defects or deviations of the nasal
septum. Rhinoplasty is surgery to reshape the nose to one that the patient finds
more desirable. When the septum is off-center or misaligned, septoplasty
(submucosal resection) is sometimes required to straightened the septum in order to
correct the breathing impairment that results from the misalignment. The nasal
passages can also be obstructed by enlarged turbinates. Chronic nasal obstruction
6
may also be associated with inferior nasal turbinate hypertrophy and turbinectomy is
often performed at the time of nasal septal surgery by many otolaryngologists.
According to the American Society of Plastic Surgeons and the American Academy of
Otolaryngology, rhinoplasty that is performed as an integral part of a medically
necessary septoplasty is performed to improve nasal respiratory function and revise
structural deformities caused by birth defects (e.g., cleft nasal deformity, which may
be associated with cleft lip and/or cleft palate, oromaxillary fistulas, absent nose
development and nasal duplication) or acquired conditions (trauma, disease, ablative
surgery). Telescoping tearing and dislocation of the septum is a frequent occurrence
in closed nasal injuries. Dislocations most frequently occur at the junction between
the quadrangular cartilage and the perpendicular plate of the ethmoid bone. Failure
to address a malpositioned septum in nasal fracture reduction may lead to eventual
nasal obstruction.
The decision for septoplasty is not typically based solely on the degree of deviation
alone. It is the accompanying functional impairment in the form of obstructed nasal
breathing and any resulting conditions, such as sinusitis. Deviations in the septum
can alter normal airflow, which may result in mucosal changes. This interference in
airflow may cause middle or inferior turbinate abnormalities. Sinus drainage may
also be compromised by deviation of the septum and can result in recurrent or
chronic sinusitis. Generally, a case is considered refractory to medical management
when there has been a sufficient period of treatment with antibiotics for infections,
intranasal steroids and decongestants.
There may be situations when, although a septal deformity may not be causing
specific symptoms, its presence is preventing surgical access to other intranasal or
paranasal areas, such as the sinuses or turbinates. Septoplasty may be medically
indicated when it is being performed to allow surgical access to these areas so that a
medically appropriate surgery may be successfully performed. Septoplasty may be
performed as part of cleft repair/reconstructive surgery or for other craniofacial
anomalies. Septoplasty may be necessary in order to allow adequate access to a
posterior vessel that is causing recurrent epistaxis. Also, where a septal deformity is
causing abnormal air turbulence, severe mucosal drying and crusting may develop
which can lead to recurrent nosebleeds.
A review of the literature does not support the efficacy of rhinoplasty/septoplasty
surgery in the treatment of obstructive sleep apnea, either performed alone or
routinely as part of another procedure such as uvulopalatopharyngoplasty (UPPP).
The surgical procedures have not been tested by appropriate randomized controlled
trial methods. The limited number of studies contains biases related to small sample
size as well as limited follow-up and patient selection. There is no convincing
evidence that these procedures reduce the severity of sleep apnea, although there
are anecdotal reports that compliance with CPAP may be improved when this therapy
continues to be required post-operatively. Septoplasty may be considered medically
necessary when there is documentation that obstructed nasal breathing due to septal
deformity or deviation is causing difficulty tolerating nasal CPAP and is refractory to
medical management.
Review History
March 2005
January 2007
Medical Advisory Council
Update. No policy revisions. Coding Updates.
7
April 2008
May 2008
August 2008
May 2010
Update. Revised policy to include documentation of obstructed
nasal breathing due to septal deformity or deviation, difficulty
tolerating nasal CPAP and refractory to medical management.
Reformatted policy statement to include a & b under #1.
Further describes degree of nasal obstruction under #8.
CA reconstructive surgery law added to Disclaimer.
Update. No revisions. Codes updated.
Patient Education Websites
English
1. American Academy of Otolaryngology – Head and Neck Surgery. Fact Sheet:
Deviated Septum. Available at:
http://www.entnet.org/healthinfo/sinus/deviated-septum.cfm
2. American Rhinologic Society. Septoplasty and Turbinate Reduction. Available at:
http://american-rhinologic.org/patientinfo.septoplasty.phtml
Spanish
1. Un servicio de la Biblioteca Nacional de Medicina de ee.uu. y los Institutos
Nacionales de la Salud. Enciclopedia médica en español. Septoplastia - Serie:
Anatomía normal. Acesso en:
http://www.nlm.nih.gov/medlineplus/spanish/ency/esp_presentations/100038_1
.htm
2. Medline Plus. Cirugía de la nariz. Acesso en:
http://www.nlm.nih.gov/medlineplus/spanish/ency/article/002983.htm
This policy is based on the following evidence-based guidelines:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of
obstructive sleep apnea in adults. 2007 Mar. 55 p. Available at:
http://www.guidelines.gov/summary/summary.aspx?doc_id=10809&nbr=00563
4&string=septoplasty
American Academy of Allergy, Asthma and Immunology/American College of
Allergy, Asthma and Immunology/Joint Council of Allergy, Asthma and
Immunology. Parameters for the diagnosis and management of sinusitis. 1998
Dec.
American Academy of Otolaryngology-Head and Neck Surgery, Inc. Research.
NOSE Study Results, Otolaryngology-Head and Neck Surgery, Bulletin, 2003
September: 42-43. Accessed at: http://www.entlink.net/research/index.cfm
American Academy of Otolaryngology-Head and Neck Surgery, Inc. Rhinoplasty.
1999 Clinical Indicators Compendium.
American Academy of Otolaryngology-Head and Neck Surgery, Inc. Septoplasty.
1999 Clinical Indicators. Accessed at:
http://www.entlink.net/practice/products/indicators/septoplasty.html
American Society of Plastic Surgeons (ASPS). Policy Statements. Nasal Surgery.
Position Paper of the American Society of Plastic Surgeons. February 2000: 1-3.
Accessed at: http://www.plasticsurgery.org/medical_professionals/publications
American Society of Plastic and Reconstructive Surgeons. Nasal Deformity. Sep
1993 (Reviewed 1997): 6 pages.
American Society of Plastic Surgeons (ASPS). Nasal Surgery. Position Paper of
the American Society of Plastic Surgeons. Sep 1994: 4 pages.
American Academy of Pediatrics. Clinical Practice Guideline: Management of
Sinusitis. Pediatrics. Volume 108, Number 3. September 2001, pp 798-808.
Available at: http://www.aap.org/policy/0106.html
8
References – Update May 2010
1.
2.
3.
Hwang PH, Getz A. Acute sinusitis and rhinosinusitis in Adults. UpToDate.
January 7, 2010. Available at:
http://www.uptodate.com/online/content/topic.do?topicKey=pc_id/5943&selecte
dTitle=48%7E150&source=search_result
Chaaban M, Shah AR. Open Septoplasty: Indications and Treatment.
Otolaryngologic Clinics of North America. Available at:
http://www.mdconsult.com/das/article/body/1949401873/jorg=journal&source=MI&sp=22209147&sid=982737945/N/700721/1.html?is
sn=0030-6665
Bloom JD, Kaplan SE, Bleier BS, et al. Septoplasty Complications: Avoidance and
Management. Otolaryngologic Clinics of North America - Volume 42, Issue 3
(June 2009).
References – Update April 2008
1.
2.
Norman D, Clin Geriatr Med. 01-FEB-2008; 24(1): 151-65, ix.
Eisenberg G, Perez C, Hernando M, et al. Nasosinusal endoscopic surgery as
major out-patient surgery. Acta Otorrinolaringol Esp. 2008 Feb;59(2):57-61.
3. Kappe T, Papp J, Rozsasi A, et al. Nasal conditioning after endonasal surgery in
chronic rhinosinusitis with nasal polyps.Am J Rhinol. 2008 Jan-Feb;22(1):89-94.
4. Getz AE, Hwang PH. Endoscopic septoplasty. Curr Opin Otolaryngol Head Neck
Surg. 2008 Feb;16(1):26-31.
5. Ozlugedik S, Nakiboglu G, Sert C, et al. Numerical study of the aerodynamic
effects of septoplasty and partial lateral turbinectomy. Laryngoscope. 2008 Feb;
118(2): 330-4.
6. Williamson IG, Rumsby K, Benge S, et al. Antibiotics and Topical Nasal Steroid
for Treatment of Acute Maxillary Sinusitis. A Randomized Controlled Trial. JAMA.
2007;298(21):2487-2496.
7. Lindbaek M. Acute Sinusitis. To Treat or Not to Treat? JAMA. Vol. 298 No. 21,
December 5, 2007. 298(21):2543-2544.
8. Rakel: Textbook of Family Medicine. 7th Edition. 2007
9. Current Allergy and Asthma Group. 1529-7322. 1534-6315. Issue Volume 6,
Number 6 / November, 2006, DOI 10.1007/s11882-006-0029-0, Pages 508-512
10. Clinical Trials. Gov. A Service of the US National Institute of Health. Guidelines
for Acute Sinusitis. Available at:
http://clinicaltrials.gov/ct2/show/NCT00132275?term=%22antibiotic+resistance
%22&recr=open&rank=14&show_desc=Y#desc
References – Initial
1.
2.
3.
4.
Masdon JL, Magnuson JS, Youngblood G. The effects of upper airway surgery for
obstructive sleep apnea on nasal continuous positive airway pressure settings.
Laryngoscope 2004 Feb;114(2):205-207.
Van Cauwenberge P, Sys L, De Belder T, Watelet JB. Anatomy and physiology of
the nose and the paranasal sinuses. Immunology and Allergy Clinics of North
America 2004 Feb;24(1):1-17.
Witterick I, Kolenda J. Surgical management of chronic rhinosinusitis.
Immunology and Allergy Clinics of North America, 2004 Feb;24(1):119-134.
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 Mar;130(3):283-90.
9
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Marshall AH, Johnston MN, Jones NS. Principles of septal correction. J Laryngol
Otol. 2004 Feb;118(2):129-34.
Rhee SC, Kim YK, Cha JH, Kang SR, Park HS. Septal fracture in simple nasal
bone fracture. Plast Reconstr Surg. 2004 Jan;113(1):45-52.
Chen W, Kushida CA. Nasal obstruction in sleep-disordered breathing.
Otolaryngologic Clinics of North America 2003 Jun:36(3):437-460.
Kim D, Toriumi DM. What’s new in otolaryngology: head and neck surgery.
Journal of the American College of Surgeons, 2003 Jul;197(1):97-114.
Muhammad IA, Nabil-ur Rahman. Complications of the surgery for deviated
nasal septum. J Coll Physicians Surg Pak. 2003 Oct;13(10):565-8.
Sindwani R, Wright ED. Role of endoscopic septoplasty in the treatment of
atypical facial pain. J Otolaryngol. 2003 Apr;32(2):77-80.
Nowak C, Bourgin P, Portier F, et al. Nasal obstruction and compliance to nasal
positive airway pressure. Ann Otolaryngol Chir Cervicofac. 2003
Jun;120(3):161-6.
Durr DG. Endoscopic septoplasty: technique and outcomes. J Otolaryngol. 2003
Feb;32(1):6-11.
Rautio J, Vento S, Malmberg H. Rhinoplasty and nasal function in patients with
cleft lips. Scand J Plast Reconstr Surg Hand Surg. 2002;36(5):268-72.
Dinis PB, Haider H. Septoplasty: long-term evaluation of results. Am J
Otolaryngol. 2002 Mar-Apr;23(2):85-90.
Collet S, Bertrand B, Cornu S, Eloy P, Rombaux P. Is septal deviation a risk
factor for chronic sinusitis? Review of literature. Acta Otorhinolaryngol Belg.
2001;55(4):299-304.
Gonzalez R, Bartlett JG, Besser RE, Hickner JM, Hoffman JR, Sande MA.
Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract
Infections in Adults: Background, Specific Aims, and Methods. Ann Intern Med
2001 Mar;134(6):479-86.
Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR, Sande MA.
Principles of Appropriate Antibiotic Use for Rhinosinusitis in Adults: Background.
Ann Intern Med 2001 Mar;134(6):498-505.
Meyers S, Rohrer T, Grande D. Use of Dermal Grafts in Reconstructing Deep
Nasal Defects and Shaping the Ala Nasi. Dermatol Surg 2001 Mar;27(3):300-5.
Mulliken JB, Burvin R, Farkas LG. Repair of Bilateral Complete Cleft Lip:
Intraoperative Nasolabial Anthropometry. Plast Reconstr Surg 2001
Feb;107(2):307-14.
Park SS. Treatment of the internal nasal valve. Otolaryngological Clinics of
North America 2001 Aug;34(4):805.
Snow V, Mottur-Pilson C, Hickner JM. Principles of Appropriate Antibiotic Use for
Acute Sinusitis in Adults. Ann Intern Med 2001 Mar;134(6):495-7.
Bateman N, Jones NS. Retrospective Review of Augmentation Rhinoplasties
Using Autologous Cartilage Grafts. J Laryngol Otol 2000 Jul;114(7):514-8.
Berger G, Hammel I, Berger R, Avraham s, Ophir D. Histopathology of the
Inferior Turbinate with Compensatory Hypertrophy in Patients with Deviated
Nasal Septum. Laryngoscope 2000 Dec;110(12):2100-5.
Boenisch Mink A. Clinical and Histological Results of Septoplasty with a
Resorbable Implant. Arch Otolaryngology Head Neck Surg 2000
Nov;126(11):1373-7.
Fedok FG, Ferraro RE, Kingsley CP, Fornadley JA. Operative Times,
Postanesthesia Recovery Times, and Complications during Sinonasal Surgery
Using General Anesthesia and Local Anesthesia with Sedation. Otolaryngology
Head Neck Surg 2000 Apr;122(4):560-6.
10
26. Foda HM, Bassyouni K. Rhinoplasty in Unilateral Cleft Lip Nasal Deformity. J
Laryngol Otol 2000 Mar;114(3):189-93.
27. Mamikoglu B, Houser S, Akbar I, Ng B, Corey JP. Acoustic Rhinometry and
Computed Tomography Scans for the Diagnosis of Nasal Septal Deviation, with
Clinical Correlation. Otolaryngol Head Neck Surg 2000 Jul;123(1 Pt 1):61-8.
28. No authors listed. What’s a Deviated Nasal Septum? Does It Need to Be
Corrected. Mayo Clin Health Lett 2000 Apr;18(4):8.
29. Siegel NS, Gliklich RE, Taghizadeh F, Chang Y: Outcomes of septoplasty.
Otolaryngol
30. Head Neck Surg 2000 Feb; 122(2): 228-32
31. Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW: Endoscopic septoplasty:
indications, technique, and results. Otolaryngol Head Neck Surg 1999 May;
120(5): 678-82
32. Reber M, Rahm F, Monnier P: The role of acoustic rhinometry in the pre- and
postoperative evaluation of surgery for nasal obstruction. Rhinology 1998 Dec;
36(4): 184-7.
33. Clement PA, Bluestone CD, Gordts F, Lusk RP, Otten FW, Goossens H, et al.
Management of Rhinosinusitis in Children: Consensus Meeting, Brussels,
Belgium, September 13, 1996. Archives of Otolaryngology Head Neck Surg
1998 Jan;124(1):31-4.
34. Kaliner M. Medical Management of Sinusitis. The American Journal of the
Medical Sciences 1998 Jul;316(1):21-8.
35. Orlandi RR, Kennedy DW. Surgical Management of Rhinosinusitis. American
Journal of the Medical Sciences 1998 Jul;316 (1):29-38.
36. Elahi MM, Frenkiel S, Fageeh N. Paraseptal Structural Changes and Chronic
Sinus Disease in Relation to the Deviated Septum. The Journal of
Otolaryngology 1997 Aug;26(4):236-40.
37. Kamami YV: Laser-assisted outpatient septoplasty results on 120 patients. J
Clin Laser Med Surg 1997; 15(3): 123-9
38. Manoukian PD, Wyatt JR, Leopold DA, Bass EB: Recent trends in utilization of
procedures in otolaryngology-head and neck surgery. Laryngoscope 1997 Apr;
107(4): 472-7
39. Yanagisawa E, Joe J: Endoscopic septoplasty. Ear Nose Throat J 1997 Sep;
76(9): 622-3.
40. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modification of
the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996
Feb;19(2):156-157.
41. Giles WC, Gross CW, Abram AC, et al: Endoscopic septoplasty. Laryngoscope
1994 Dec; 104(12): 1507-9
42. Godley FA, Nemeroff RF, Josephson JS. Current trends in rhinoplasty and the
nasal airway. Med Clin North Am. 1993;77(3):643-656.
43. Lund VJ. Office Evaluation of Nasal Obstruction. Otolaryngologic Clinics of North
America 1992 Aug;25(4):803-15.
44. Series F, St Pierre S, Carrier G. Effects of surgical correction of nasal obstruction
in the treatment of obstructive sleep apnea. Am Rev Respir. Dis.1992
Nov;146(5 Pt 1):1261-1265.
45. Huerter JV. Functional endoscopic sinus surgery and allergy. Otolaryngol Clin
North Am. 1992;25(1):231-238.
46. Clarke RW, Jones AS: Nasal airflow receptors: the relative importance of
temperature and tactile stimulation. Clin Otolaryngol 1992 Oct; 17(5): 388-92
47. Samad I, Stevens HE, Maloney A: The efficacy of nasal septal surgery. J
Otolaryngol 1992 Apr; 21(2): 88-91
11
Important Notice
General Purpose.
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering
plan benefits and determining whether a particular procedure, drug, service or supply is medically
necessary. The Policies are based upon a review of the available clinical information including clinical
outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device,
evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select
national health professional organizations. Coverage determinations are made on a case-by-case basis
and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract,
including medical necessity requirements. Health Net may use the Policies to determine whether under the
facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically
necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not
constitute coverage. The member's contract defines which procedure, drug, service or supply is covered,
excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current
criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical
criteria and medical policies provide guidelines for determining the medical necessity criteria for specific
procedures, equipment, and services. In order to be eligible, all services must be medically necessary and
otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all
cases, final benefit determinations are based on the applicable contract language. To the extent there are
any conflicts between medical policy guidelines and applicable contract language, the contract language
prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it
intended to dictate to providers how to practice medicine.
Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined
by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for
prior notification. If there is a discrepancy between the policy effective date and legal mandates and
regulatory requirements, the requirements of law and regulation shall govern. * In some states, new or
revised policies require prior notice or posting on the website before a policy is deemed effective. For
information regarding the effective dates of Policies, contact your provider representative. The Policies do
not include definitions. All terms are defined by Health Net. For information regarding the definitions of
terms used in the Policies, contact your provider representative.
Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some
states, new or revised policies require prior notice or website posting before an amendment is deemed
effective.
No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to
members. Members should consult with their treating physician in connection with diagnosis and
treatment decisions.
No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service
or supply. Members and providers should refer to the Member contract to determine if exclusions,
limitations, and dollar caps apply to a particular procedure, drug, service or supply.
Policy Limitation: Member’s Contract Controls Coverage Determinations.
The determination of coverage for a particular procedure, drug, service or supply is not based upon the
Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the
member’s contract, and requirements of applicable laws and regulations. The contract language contains
specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums,
eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also
known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies,
the Member’s contract shall govern. Coverage decisions are the result of the terms and conditions of the
Member’s benefit contract. The Policies do not replace or amend the Member’s contract. If there is a
discrepancy between the Policies and the Member’s contract, the Member’s contract shall govern.
Policy Limitation: Legal and Regulatory Mandates and Requirements.
The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable
legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal
mandates and regulatory requirements, the requirements of law and regulation shall govern.
12
Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive
surgery. “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of
the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease
to do either of the following:
(1) To improve function or
(2) To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape
normal structures of the body in order to improve appearance.
Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal
improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by
physicians specializing in reconstructive surgery.
Policy Limitations: Medicare and Medicaid.
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and
determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid
members shall not be construed to apply to any other Health Net plans and members. The Policies shall
not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.
13

National Medical Policy

Transcription

Similar documents

Rhinoscopy

MAD®Nasal - OnMedical

OxyFlow™ Literature - Medical Innovations

Sinusin - Heavenly Herbs and Acupuncture

All the Essential Elements You Deserve in a

FESS (Functional Endoscopic Sinus Surgery) and Nasal Polypectomy

ADENOIDECTOMY

Extracorporeal septoplasty- correcting the difficult septal deformity

rhinolithiasis: review of the literature with case reports