Aetna Health Insurance: Frequently Asked Questions

Aetna_FAQ

All insurance carriers have specific criteria when it comes to determining the amount of coverage the company is willing to extend towards medical treatment. Aetna is no exception. Within the various types of policies offered by the company, nose surgery is one area in which Aetna offers full coverage. Out-of-pocket costs will be minimal for the patient who exhibits specific symptoms showing that treatment is necessary for the maintenance of good health.

Read below for a list of frequently asked questions about Aetna health insurance policies as they apply to deviated septum surgery, sinus surgery and rhinoplasty. Learn about what it means when your surgery is characterized as “medically necessary,” understand how Aetna determines septoplasty coverage, differentiate between a cosmetic and functional procedure, and more. This article is meant to serve as a guide for Aetna customers considering nasal surgery.

Aetna & Deviated Septum Surgery Coverage

Useful Terms & Policy Information

Is my treatment “medically necessary”?

Aetna extends coverage to policy holders for procedures deemed “medically necessary.” Thus, when submitting a claim to your insurance company, it will benefit you if your procedure meets this standard.

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Whether your procedure is “medically necessary” can be the difference between full coverage and paying out-of-pocket.

Whether treatment is medically necessary depends heavily on the judgment of the physician. The doctor must believe that the procedure or surgery is an appropriate means of assessing, diagnosing or treating either the illness, disease or its symptoms. The physician’s judgment is also held to a certain benchmark, determined by generally accepted standards of medicine. These standards are compiled based on diagnoses by physicians in the same practice, medical journals reviewed by physicians’ peers and other comparable factors. A medically necessary procedure must be not only clinically suitable, but also an effective approach to treat patient’s injury or ailment.

Just because a surgery or procedure is convenient to either the doctor or the patient, does not mean that it is medically necessary. If a less costly treatment plan exists that will produce equal results, then the more expensive procedure will not be covered.

The exact criteria to determine whether a procedure is “medically necessary” varies from procedure to procedure. Your Aetna policy will have an exact definition of what the term means as applied to your surgery.

What is a septoplasty?

A septoplasty, also called a nasal septoplasty, is performed to augment a deviated nasal septum. A deviated septum can inhibit normal functioning of the nose, creating difficulty breathing, nasal congestion and other breathing issues.

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A septoplasty might sometimes improve the shape of your nose, but for coverage to apply, it must not be the main goal of the procedure.

Sometimes a septoplasty can incidentally improve the outward appearance of the nose, but insurance providers remind patients that the main reason for the procedure must be medically necessary.  Aetna will not cover a nasal septoplasty for asymptomatic patients.

When is a septoplasty surgery “medically necessary?”

To determine whether a septoplasty is medically necessary, Aetna supplies five diagnoses, one of which must be met for coverage to apply.
Scroll down for a useful chart outlining each benchmark.

Aetna Benchmarks: Septoplasty

1. The patient is asymptomatic, but the septum is deformed in such a way that inhibits other medical necessary surgeries (e.g. sinus surgery)

2. The patient suffers from frequent sinus infections (chronic sinusitis) and medical/antibiotic treatment has produced no improvements in the patient’s condition

3. The patient’s septum is deformed in a way that causes repeated nosebleeds (epistaxis)

4. The septal deformity causes nasal obstruction, making it difficult for the patient to breathe, and despite 4+ weeks of treatment with nasal sprays and antibiotics, there is no visible improvement

5. Treatment of a deviated septum is necessary in conjunction with a cleft palate repair.

When is sinus surgery necessary?

Sinus surgery is often performed to treat chronic and acute sinusitis, a condition causing inflammation in the sinus mucosa.  Endoscopic Sinus Surgery (ESS) is typically the preferred treatment method for those with chronic sinusitis and acute sinusitis. Before Aetna will extend coverage for an ESS procedure, you will be required to send a copy of a CT (computed tomography) scan as evidence of the extent of the condition. Aetna prefers CT images because it is an effective way of showing the condition of the four paranasal sinuses and orbits.

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Aetna requires copies of the CT scans used in conjunction with your doctor’s diagnosis of chronic sinusitis.

Sometimes a septoplasty may be performed to treat chronic sinusitis. A deviated septum can often create negative effects on the sinuses, particularly the sinus ostium. The sinus ostium connects the sinuses to the nasal cavity. It is lined with cilia, which serve to filter the air we breathe and get rid of dirt and bacteria.

A deviated septum can block the sinus ostium, causing inflammation and fluid build-up in the surrounding paranasal sinuses. Thus, in lieu of ESS, a septoplasty will be performed to straighten the septum and remove the blockages in the sinus ostium.

What is an “experimental and investigational” procedure?

If a procedure is not determined to be medically necessary, then your insurance company might classify it as “experimental and investigational.” This means that your provider does not consider the surgery an effective means to treat your symptoms and will decline to cover the costs associated with it.

As a good rule of thumb, if your surgery is not directly linked as a treatment option for a certain condition or illness, then it is likely experimental.

When might a septoplasty be considered “experimental and investigational”?

According to Aetna, septoplasty performed that will not produce proven, medically effective results is experimental. The five diagnoses listed in the chart above are the only approved conditions that warrant a septoplasty. Thus, for example, if your surgeon performed a septoplasty to treat allergic rhinitis, Aetna will deny coverage, since the efficacy of this treatment has yet to be successfully proven by generally accepted standards of medicine

Is there more than one type of septoplasty?

Yes. There are two types of septoplasty procedures: a standard septoplasty and an extracorporeal septoplasty. The latter refers to a more intensive form of septoplasty to repair markedly deviated septums. Aetna will cover an extracorporeal septoplasty if the surgeon determines that it is necessary to correct an severely deviated nasal septum that could not otherwise be adequately improved via a standard septoplasty.

Note: Patients undergoing an extracorporeal septoplasty must also meet the five criteria to which septoplasty candidates are subjected.

Note: Aetna does not cover extracorporeal septoplasty when the procedure is merely a revision septoplasty.

Aetna & Rhinoplasty Coverage

Useful Terms & Policy Information

What is “elective” or “cosmetic” surgery?

A surgical procedure falls into one of two categories: medically necessary or elective/cosmetic. As explained above, a medically necessary surgery is one that is crucial to resolving an illness or health issue. Your insurance provider will outline a list of symptoms that must match your diagnosis. If you successfully meet the requirements, then your insurance provider will cover the costs of the surgery or treatment plan recommended by your doctor.

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Elective or cosmetic plastic surgery procedures are typically not covered by Aetna insurance policies.

On the other hand, if your symptoms do not match those outlined by your insurance provider, your surgery may be “elective” or “cosmetic.” An elective procedure is one that is not necessarily tied to any critical treatment plan. It is merely cosmetic – or a surgery that will result in a more attractive appearance or to correct a deformity that presents no health risks or complications.

Most insurance companies chose not to cover the costs of a procedure deemed cosmetic, since it is not related to curing any illness detrimental to your health. A cosmetic rhinoplasty is generally considered an elective procedure, as are face lifts, breast augmentations and brow lifts. If you are unsure about whether your procedure is medically necessary or cosmetic, check with your provider and reflect on whether the surgery will cure a specific health issue, or merely enhance your appearance.

What is a rhinoplasty?
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A rhinoplasty can be performed as an “open” or “closed” procedure.

A rhinoplasty can be elective or cosmetic. Regardless of the type of rhinoplasty, the way the procedure is performed is generally the same. There are two distinct approaches: the internal, “closed” approach (when the surgeon accesses the interior of the nose through the nostrils, without making an incisions) or the external, “open” approach (when the surgeon makes a small incision between your nostrils to access the structure of the nose.) The approach used by your surgeon heavily depends on whether minor or extensive structural changes are necessary.

Whether the approach is open or closed, a functional rhinoplasty involves making changes to several areas of the nose. There are four major parts of the nose that your surgeon may augment:

External Nasal Valve (the opening of the nose)

Internal Nasal Valve (the middle third of the nose where cartilage attaches to the septum)

Nasal Septum (the wall in the middle of the nose that separates the nasal cavities) and

Turbinates/Nasal Concha (tissue located in the nasal passageways that direct airflow and humidify/filter air)

When considering a cosmetic rhinoplasty, function must be maintained. It would be imprudent to get a cosmetically perfect nose if you can’t breathe through it. Cosmetic changes should bring aesthetic improvement to the nose without causing a functional problem.

In order for your surgeon to change the shape or function of the nose, he may use bone or cartilage grafts to build up a nose that is too small or appears collapsed. Bone or cartilage grafts can be taken from the ear or the rib, most commonly, and are usually sourced from donors.

Aetna Benchmarks: Rhinoplasty

1. Rhinoplasty for the purpose of fixing a cleft lip

2. Rhinoplasty to improve nasal airflow

Note: Aetna-insured patients must meet 12 distinct symptoms for this exception to apply,    including nasal deformity, prolonged difficulty breathing, ineffective results from prior septoplasty, evidence of failed treatment programs, test results, among others.

3. Rhinoplasty to correct a gross nasal deformity

What is the difference between a “functional rhinoplasty” and a “cosmetic rhinoplasty”?

A functional rhinoplasty is a surgery to change the shape of the nose to improve nasal breathing. The three exceptions listed in the chart above are all examples of health issues that justify a functional rhinoplasty. By contrast, a cosmetic rhinoplasty is performed not for any particular health issue, but merely to enhance the appearance of the nose.

When is a rhinoplasty procedure medically necessary”?

Like most all insurance carriers, Aetna classifies rhinoplasty as a purely elective, cosmetic procedure. Cosmetic procedures are never deemed medically necessary, limiting cost coverage, unless you meet one of three exceptions carved out by Aetna.

What should I do if I have a specific question about my policy?stethescope

If you have a specific question about your Aetna policy, call 1-800-US-AETNA or create an account at https://member.aetna.com/ to view the detailed information about your coverage, search for doctors or chat online with a representative.