The first step in identifying your coverage qualification for sinus surgery from United Healthcare is having your condition assessed and documented. Many insurance companies will base the coverage amount from what is documented by a physician. A lot of the time, coverage depends on what kind of insurance plan you have with the company, and what they consider a medically necessary procedure.
United requests the following documentation before offering coverage for sinus surgery:
- A documented history of medical conditions that require treatment or surgical intervention. This documentation must include the initial discovery of the any conditions and their general reoccurring progression. It also requires that symptoms are tracked, from both topical and surgical treatments.
- In addition, United requires a history of symptoms occurring from sinus and nasal conditions that are in need or surgery.
- Third, United asks that a proper documented history of any and all treatments already taken be presented. This can range from the smallest topical treatments to any previous surgery.
- Lastly, they require the documentation of results from an ‘external nasal and intranasal evaluation.’
- Thereafter, United requests that the proper tests and studies are done per a patients need. These tests will confirm medical history, as well as help understand where the problem lies and why it’s causing an impairment. The tests include a signed CT report as well as any other radiologic test, MRI’s and any specific photographs.
Septoplasty, when met under certain guidelines, is considered reconstructive. In the case of sleep apnea, a confirmation by polysomnogram showing that the apnea index at a 5 or greater that has an intolerance because of nasal obstruction that is caused by nasal septal deviation. If the apnea result is not available respiratory disturbance of 5 or is also acceptable.
Secondly, is there is reoccurring epistaxis that is secondary to septal deformity or a chronic sinusitis. Sinusitis must have been going on for at least 5 months.
Finally, if you suffer from constant struggles with breathing which force you to breathe through your mouth, surgery is often covered.
United also requires documentation stating that the nasal airway is obstructed and the primary cause of obstructed breathing. Before United will consider coverage of sinus surgery, they will make sure that the maximum effort in medical treatment has already been delegated and proven failed in order to proceed with the next step in treatment.
In only one case of reconstructive septoplasty is treatment covered. When a trauma has occurred causing not only deformity but more important problems breathing or other nasal activity that was once normal before the trauma, United considered the procedure to be covered under their insurance.
In most medical cases, rhinoplasty is a formal term for ‘nose job,’ and isn’t normally covered by insurance. There are though, some specific cases by which rhinoplasty is covered by insurance. United states that if the repair of nasal vestibular stenosis or alar collapse is considered reconstructive if:
- There has been long lasting, persistent obstructed nasal breathing due to internal aor external nasal valve problems. This means that if you’re breathing is in any way altered because of the shape of your nose, it can be considered a medically necessary procedure.
- Internal or external nasal valve compromise cause nasal airway obstruction and is the main factor for obstructed nasal breathing.
- Lastly, any and all other possibilities of obstruction have already been eliminated, and the primary cause has been determined as only treatable through rhinoplasty.
- Rhinoplasty is also considered a medical necessity when it is performed alongside surgery to treat a functionally impairing cleft lip or cleft palate.
When any of the previously mentioned criteria are not met based on United assessment of treatment, then coverage is not considered a medical necessity and therefore not covered by United.
This includes surgery that is only successful in improving appearance.
The specifics of what is and is not covered by United 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 United insurance and sinus treatments.
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