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
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.
Whether treatment is medically necessary depends heavily on the judgment of the physician. The doctor must believe that the procedure or surgery is appropriate for 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.
A septoplasty, also called a nasal septoplasty, is performed to straighten a deviated nasal septum. A deviated septum can inhibit normal functioning of the nose, creating difficulty breathing, make you more prone to sinus infections, cause nasal congestion and even lead to obstructive sleep apnea.
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 necessity. Aetna will not cover a nasal septoplasty for asymptomatic patients.
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
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.
Sinus surgery is often performed to treat chronic and acute sinusitis and the resultant inflammation in the sinus mucosa. Functional Endoscopic Sinus Surgery (FESS) is typically the preferred treatment method for those with chronic sinusitis and recurrent acute sinusitis. Before Aetna will extend coverage for an FESS procedure, your doctor must perform endoscopy of you sinuses and obtain a CT (computed tomography) scan as evidence of the extent of the condition. Aetna uses sinus CT images as an effective way of showing the condition of the four paranasal sinuses and orbits.
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. Each of the many sinuses have openings into the nasal cavity which drain the sinuses to the nasal cavity. The sinuses and inside of the nose are 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 or along with a FESS, a septoplasty will be performed to straighten the septum and potentially remove the blockages of the sinus ostium.
Sometimes balloon sinuplasty is considered medically necessary and sometimes it is not. There are many studies that show that the balloon sinuplasty is effective but the insurance companies may try to avoid the additional cost of the balloons if possible. Your doctor’s office should pre-approve balloon sinuplasty or you may end up getting an additional bill for use of the technology.
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.
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
Yes. There are two types of procedures: a standard septoplasty and an extracorporeal septoplasty. The latter refers to a more intensive form of septoplasty to repair markedly deviated septums and involves complete removal and replacement of the deviated septum in the nose. 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 one of 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
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.
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 (a surgery that will result in a more attractive appearance) or to correct an aesthetic 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.
A rhinoplasty can be medically necessary, 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 skin incisions) or the external, “open” approach (when the surgeon makes a small incision between your nostrils to access the structures of the nose.) The approach used by your surgeon heavily depends on surgeon preference and whether minor or extensive structural changes are necessary.
Whether the approach is open or closed, a functional rhinoplasty, which is deemed as medically necessary, involves making changes to one of more of several areas of the nose. There are four major parts of the nose that your surgeon may augment or reduce with the External and Internal Nasal Valves the most common reason:
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 medically necessary rhinoplasty the goat must be to improve the function of the nose. For 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 nasal septum, the ear, and rib which can be harvested from the patient and can also be sourced from donors.
Aetna Benchmarks: Covered Rhinoplasty
1. Rhinoplasty for the purpose of fixing a cleft lip
2. Rhinoplasty to improve nasal airflow
Note: Aetna insured patients must meet a combination of 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
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.
Like most all insurance carriers, Aetna classifies rhinoplasty for the sole purpose of changing the appearance of the nose 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.
If you have a specific question about your Aetna policy, call 1-800-US-AETNA or create an account at https://www.aetna.com/ to view the detailed information about your coverage, search for doctors or chat online with a representative. Navigating through insurance is complex so expect to spend a significant amount of time obtaining your benefits.
If you are a patient of Dr. Bennett, our office will check your Aetna benefits and let you know what your responsibilities are before any office visit or procedures. We have a “no surprise” policy when it comes to billing. We also deal with insurance providers on a daily basis and will ask all of the appropriate questions to get you the benefits and coverage that you deserve.