An Insurance Decision That Made No Sense

An underdiscussed topic in our field is the way in which decisions by payers can prevent the delivery of high-value, patient-centered care and increase cost. One recent example occurred in a procedure that represents a large part of my practice. My hope is that this example from my field will resonate with our community, as other physicians have most certainly faced similar issues in their practice. 

On Jan. 1, 2023, United Healthcare changed its policy for nasal valve repair (NVR), requiring that patients undergo both a turbinoplasty and a septoplasty prior to approving the code for NVR. This disregarded the wealth of publications that demonstrate the efficacy of NVR in patients with nasal valve compromise (NVC) and the high rate of failure of septoplasty in this patient population, it ignored clinical practice guidelines, and it seemingly didn’t utilize the systems in place with the American Academy of Otolaryngology–Head and Neck Surgery to review policies prior to change. 

All surgery has potential risks, which is why the informed consent process is so important. However, United’s policy change placed surgeons in a difficult position: Either perform a surgery that you knew would not only not work but would also make the second operation more difficult, or defer care. 

In my practice, like in many others, patients with NVC are referred to me by members of our community who have already seen and examined them and have determined that a septoplasty or turbinoplasty alone or in combination won’t correct the patient’s symptoms. Documentation of this in the chart didn’t seem to matter to United; a hard stop was placed on approving the NVR code unless the patient had had a previous septoplasty and turbinoplasty. This seemed ridiculous to those of us who commonly care for these patients and who have spent years researching the disease-specific and global quality of life improvement seen after NVR. Why would an insurance company mandate a procedure that isn’t indicated and require patients to undergo an ineffective surgery that increases the cost of care? I don’t have answers to these questions.

This policy change did demonstrate the efforts that can be made by our academies and societies that worked quickly to advocate for a change to the policy. Their tireless efforts resulted in a win for our patients who, once United revised their policy, were then approved to have the correct operation to treat their nasal obstruction. Time will tell if United’s preapproval results in approval for payment after the surgery.

While it was tremendous to see the effort to overturn the flawed policy, I can’t help but question why this effort was needed considering the time required, healthcare dollars wasted, and the patients who had to wait for appropriate care despite having insurance and a surgeon. The real question is, what can we do as surgeons to prevent this from occurring with other procedures? 

—Robin