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Does Aetna Cover Sinus Surgery?

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Under Aetna, sinus surgery is covered when criteria for medically necessary septoplasty is needed. A number of different things constitute to what is considered a medically necessity and what isn’t. Aetna describes some of the following:

  • A deformity that obstructs any other function of the nasal area may require a surgical procedure.
  • If sinusitis is present even after medical treatment has been performed and medications have been prescribed, tests may determine that septoplasty is the only solution to the ongoing problem.
  • If you suffer from a history of chronic nosebleeds
  • If your breathing is obstructed and you find yourself breathing heavily from the nose, treatment can be offered after a record of unsuccessful medical therapy is shown to have been tested for at least four weeks.
  • If you are seeking surgery to accompany the treatment of a cleft palate

Aetna considers septoplasty medically necessary for the correction of a deviated nasal septum that cannot be corrected with any other approach.

For the most part, Aetna considers rhinoplasty a cosmetic procedure. There are although certain terms by which rhinoplasty can be considered to be a medically necessary procedure. After thorough tests and documentation have been presented to show that the only solution to issues of the nasal septum is rhinoplasty, Aetna may consider the procedure a medical necessity.

Aetna describes cases by which rhinoplasty might be considered a medical necessity:

  • Obstruction of breathing that has been long running and consistent
  • Confirmed moderate to severe nasal obstruction
  • An obstruction to the airway that does not respond to any other sinus surgery treatments
  • Symptoms that persist or resume even after a trial of medical therapy of at least four weeks. This includes medication, steroids or any other nasal procedure that was previously performed.
  • Evidence (usually photographically) that show the external deformity in either one of both of the nasal nares.

The evidence that Aetna requests must all show documentation of what has been tried and what has not been tried. Aetna likes to makes sure that every step has been taken before proceeding with a rhinoplasty procedure. For many sinus cases, it is uncommon that rhinoplasty is the answer, but if it is suggested by a physician then they must understand why nothing else has worked and if everything that can be done has been done.

Cosmetic:

Like most other insurance carries, Aetna considers any procedure that is meant solely for the purpose of enhancing appearance not a medical necessity. Cosmetic septoplasty and rhinoplasty are not covered by Aetna. They suggests that patients make sure the criteria for a medically appropriate surgery are met, thereafter assessing what can be done and what parts of it they will cover. If no harm is being done to the nasal cavity, breathing or long standing symptoms of nosebleeds and nasal airway movement, Aetna will likely consider the surgery a cosmetic procedure.

The specifics of what is and is not covered by Aetna for sinus surgery is detailed and specific. If you have questions that pertain to your individual case that were not mentioned here, please call us at (855) 690-0565 to learn more about Aetna insurance and sinus treatments.

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