A physician performs a rhinoplasty on a 2-year-old male with nasal breathing problems. The child was born with a congenital cleft lip and palate with nasal deformity. The cleft and partial deformity was repaired when the boy was an infant, but the breathing problems have persisted, and are a direct result of the congenital nasal deformity. Now that the child can withstand a more intensive procedure, the surgeon performs the rhinoplasty to complete the correction of the deformity. What will likely happen with the processing of this claim, as long as they receive documentation of the procedure’s medical necessity?
Explanation
Answer: B - During the processing of the claim, insurance will likely pay for the claim as medically necessary. Even though it is a rhinoplasty, which can be done as a cosmetic procedure, in this case it is considered medically necessary due to the fact that the child is experiencing breathing problems from the congenital deformity and needs a rhinoplasty to correct the problem. If the procedure was purely for cosmetic reasons (if the patient wanted simply to change the shape of his nose), then insurance would not pay for it, as it would not be medically necessary.
