ModifiedAlliance HealthPolicy 1-O-5

Rhinoplasty and Septoplasty Coverage

Defines Medicaid coverage, eligibility, and medical necessity criteria for rhinoplasty, septoplasty, and septorhinoplasty for NC Medicaid beneficiaries, including EPSDT exceptions for beneficiaries under 21.

Policy Summary

PayerAlliance Health

PolicyRhinoplasty and Septoplasty Coverage

Policy CodePolicy 1-O-5

Change TypeMaterial revisions to septoplasty criteria and documentation

Effective DateAmended April 15, 2025

Next Review Date

Key ActionObtain prior authorization and submit required supporting documentation (including infection and epistaxis counts and pre-op photos) before performing most rhinoplasty or septoplasty procedures.

SourceLink

POLICY UPDATE CHANGES

Created a new subsection specifically for septoplasty criteria and added/clarified multiple septoplasty indications (including recurrent sinusitis defined as four or more episodes in a year, recurrent epistaxis of four or more significant episodes, performed with cleft repairs).

Added documentation requirements including number of sinus infections in last 365 days, number of epistaxis episodes when applicable, and postoperative plan of care.

Removed the table of CPT codes that do not require prior approval.

under 21EPSDT exception applies to beneficiaries under this age

4+Episodes threshold for recurrent sinusitis/epistaxis

18 moTrauma timeframe for covered rhinoplasty

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RequiredPrior approval

NC MedicaidGoverning program

Coverage Criteria for Rhinoplasty and Septoplasty

inv-01: Rhinoplasty - Specific Covered Indications

Medicaid shall cover rhinoplasty and septoplasty procedures when the beneficiary meets the following criteria:

Rhinoplasty covered indications

Congenital craniofacial deformity: Nasal deformity secondary to a congenital cleft lip, palate, or another congenital craniofacial deformity causing a functional impairment.
Reconstruction after disease: Reconstruction following removal of a nasal malignancy, an abscess, or osteomyelitis that has caused severe deformity and breathing difficulty.
Post-traumatic deformity: Deformity caused by documented trauma within the previous 18 months.18 months

Note: See subsection 3.2.1 for full rhinoplasty and septoplasty criteria.

inv-02: Rhinoplasty - Covered indications

Covered when ANY of the following for rhinoplasty are met:

1: Nasal deformity secondary to a congenital cleft lip, palate or another congenital craniofacial deformity causing a functional impairment.

2: Reconstruction following removal of a nasal malignancy, an abscess, or osteomyelitis that has caused severe deformity and breathing difficulty.

3: Deformity caused by documented trauma within the previous 18 months.18 months

inv-03: Septoplasty - Covered indications

Covered when ANY of the following for septoplasty are met:

A: Septal deviation that causes continuous nasal airway obstruction, resulting in nasal breathing difficulty that does not respond to appropriate medical therapy.

B: Four or more documented episodes of recurrent sinusitis in the last 365 days with exacerbations secondary to a deviated septum that do not resolve after appropriate medical and antibiotic therapy.>=4 in 365 days

C: Four or more documented episodes of recurrent epistaxis with exacerbations related to a septal deformity.>=4

inv-04: Septoplasty / Rhinoplasty criteria (summary)

Coverage criteria for septoplasty and rhinoplasty procedures (see subsections 3.2.1.1 and 3.2.1.2 for full criteria).

Septoplasty criteria highlights: New subsection 3.2.1.2 created with criteria for septoplasty; includes recurrent sinusitis defined as four or more episodes in a year that does not resolve after appropriate medical and antibiotic therapy; recurrent epistaxis defined as four or more significant episodes; performed in association with cleft lip or cleft palate repair is included.recurrent = >=4 episodes/year

Full nested criteria located in the referenced subsections

Medicaid does not cover procedures that are primarily for convenience. Specifically, services must be individualized, specific, and consistent with the beneficiary’s symptoms or a confirmed diagnosis, not be provided in excess of the beneficiary’s needs, and must be furnished in a manner that is not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider. Coverage also requires that the service can be safely furnished and that no equally effective and more conservative or less costly treatment is available statewide before authorization is granted.

Rhinoplasty and septoplasty performed solely to improve appearance are not covered under this policy. Additionally, rhinoplasty to correct deformity caused by trauma is covered only when performed within 18 months of the documented traumatic event; procedures performed more than 18 months after the documented trauma are not covered.

Editorial revisions were made to subsection 4.2.1.a to remove language that previously listed non-inclusive items, and subsection 4.2.1.b was edited to remove the single word "significant." These are editorial clarifications and do not add new coverage entitlements.

Services that are not individualized or are inconsistent with the beneficiary’s symptoms or a confirmed diagnosis may be denied as not medically necessary. Denial may also apply when a service is provided primarily for convenience, is in excess of the beneficiary’s needs, or when an equally effective, more conservative, or less costly treatment is available statewide. Providers must ensure documentation supports individualized medical necessity and that less invasive options were considered or attempted when applicable.

Procedures that do not meet the eligibility requirements in Section 2.0 or the specific clinical criteria in Section 3.0 are not covered. Coverage will also be denied for duplicate services, investigational or experimental procedures, or those that fail to meet the documented criteria—this includes rhinoplasty performed for cosmetic reasons or beyond the 18-month post‑trauma window. Providers should confirm eligibility and criteria adherence before submitting prior approval requests.

This extract does not contain explicit text labeled as specific "not medically necessary" (NMN) statements beyond the general NMN principles and the revisions described. Policy updates note changes to criteria and editorial language, but the document portion available here does not include separate, enumerated NMN statements.

Coding and Related Thresholds

Procedure codes requiring prior approvalCPTCovered

30400	CPT Code listed requiring prior approval
30410	CPT Code listed requiring prior approval
30420	CPT Code listed requiring prior approval
30430	CPT Code listed requiring prior approval
30435	CPT Code listed requiring prior approval
30450	CPT Code listed requiring prior approval

Recurrent sinusitis or epistaxis episodes — threshold

ThresholdFour or more episodes in the last 365 days

Lookback period365 days

Applies toRecurrent sinusitis or recurrent epistaxis when exacerbations are secondary to septal deformity

Post-trauma timing

Time limit after traumaWithin 18 months of documented trauma

Not covered ifMore than 18 months after the documented trauma

Relevant to

Provider Actions, Prior Approval, and Documentation

Denial Risk

General medical necessity denial triggers

Medicaid will deny services that are not individualized, not consistent with a confirmed diagnosis, provided primarily for convenience, or when equally effective and more conservative or less costly alternatives exist statewide. Providers must ensure services are specific to the beneficiary's needs and supported by clinical documentation demonstrating medical necessity.

Services that are not individualized, specific, and consistent with symptoms or a confirmed diagnosis
Services that are primarily for the convenience of the beneficiary, caregiver, or provider
Services where an equally effective and more conservative or less costly treatment is available statewide

Denial Risk

Denial triggers

Medicaid will not cover procedures when the beneficiary fails to meet eligibility (Section 2.0) or coverage criteria (Section 3.0), when the service duplicates another provider's service, or when the procedure is experimental, investigational, or part of a clinical trial. Rhinoplasty and septoplasty specifically are not covered when performed to improve appearance or more than 18 months after documented trauma that caused the deformity.

Definitions

Rhinoplasty, septoplasty, septorhinoplasty (general)

PurposeSurgical procedures to correct nasal contour, septal deformities, or combined functional issues

ScopeIncludes cosmetic and reconstructive indications

Procedures includedRhinoplasty, septoplasty, septorhinoplasty

Rhinoplasty

DefinitionSurgery altering contours of the nose without involving underlying septa

Functional benefitCan correct impaired breathing caused by structural defects

Covered indications (examples)

Background

Rhinoplasty alters nasal contours and may address breathing impairment; septoplasty corrects deformities of the nasal septum; and septorhinoplasty combines external nasal skeleton and septal repairs to correct functional impairments. These procedures are used to correct congenital deformities, disease-related defects, or trauma‑related injuries and—when meeting the policy criteria—may be covered to restore form and function.

Revision History and Policy Changes

2025-04-01material_revision

Created a new subsection for septoplasty criteria (3.2.1.2) and added/clarified multiple septoplasty indications including recurrent sinusitis defined as four or more episodes in a year that does not resolve after appropriate medical and antibiotic therapy; recurrent epistaxis threshold updated to four or more significant episodes; septoplasty performed with cleft lip/palate repair added; documentation requirements expanded to include number of sinus infections in last 365 days, number of epistaxis episodes when applicable, and a postoperative plan of care; removed table of CPT codes that do not require prior approval; moved definitions into Definitions and removed '/or' from the policy title.

2025-04-15editorial_clarificationLatest

Clarified that changes to specific criteria for septoplasty and rhinoplasty are located in subsection 3.2.1 and noted that earlier references to multiple subsection numbers were listed in error.

Policy Summary

PayerAlliance Health

PolicyRhinoplasty and Septoplasty Coverage

Policy CodePolicy 1-O-5

Change TypeMaterial revisions to septoplasty criteria and documentation

Effective DateAmended April 15, 2025

Next Review Date

SourceLink

On This Page

Septoplasty performed in association with a cleft lip or a cleft palate repair.

E: Asymptomatic septal deformity that prevents access to other intranasal areas when such access is required to perform medically necessary surgical procedures.

F: Deformities of the bony nasal pyramid that directly cause symptomatic airway compromise, sleep apnea, or chronic rhinosinusitis when these conditions are not responsive to appropriate medical management.

Rhinoplasty coverage for trauma-related deformity

Recurrent sinusitis/epistaxis episode threshold

Episode threshold4 or more episodes in a year

Documentation requiredNumber of sinus infections in the last 365 days when applicable

Clinical contextApplies when exacerbations are related to a deviated septum and do not resolve after appropriate medical and antibiotic therapy

Beneficiary does not meet Section 2.0 eligibility requirements
Beneficiary does not meet Section 3.0 coverage criteria
Duplicate of another provider's procedure, product, or service
Experimental, investigational, or clinical trial procedures
Rhinoplasty/Septoplasty performed to improve appearance (not covered)
Rhinoplasty/Septoplasty performed > 18 months after documented trauma (not covered)

Prior Authorization

Prior Authorization Required

Prior approval is required for most rhinoplasty and septoplasty procedures. The rendering provider must submit a prior approval request and supporting health records to NC Medicaid's vendor. For beneficiaries under 21, prior approval is still required and documentation must demonstrate EPSDT medical necessity.

Submit the prior approval request to NC Medicaid's vendor
EPSDT: Beneficiaries under 21 still require prior approval and documentation must show EPSDT medical necessity

Documentation Required

Required documentation for prior approval

The rendering provider shall include all health records and supporting documentation demonstrating that the beneficiary meets the specific coverage criteria. This must accompany the prior approval request.

Location and cause of the defect or deformity
Pre-operative medical photographs (frontal, lateral, columellar) clearly labeled with patient name, ID number, provider name and NPI, and date
List of CPT codes describing the procedure to be performed
Documentation of frequency, severity, and description of symptoms
Documentation of the number of sinus infections in the last 365 days, when applicable
Documentation of the number of episodes of epistaxis, when applicable
Description of bodily function that will be improved or restored
Medical records documenting history of trauma or injury, date of injury, and related surgeries (if applicable)
Documentation of sleep apnea and breathing obstruction, including consecutive treatments rendered (if applicable)
Postoperative plan of care
If beneficiary is under 21: evidence that EPSDT criteria are met and any available evidence-based literature supporting the request

Documentation Required

Required clinical documentation

When applicable, include specific clinical data such as counts of infections or bleeding episodes and a clear postoperative plan to support medical necessity and expected benefit.

Number of sinus infections in the last 365 days (when applicable)
Number of episodes of epistaxis (when applicable)
Postoperative plan of care

Billing Rule

Coding specificity and unlisted code guidance

Report diagnosis and procedure codes to the highest level of specificity that supports medical necessity. Use current ICD-10-CM, PCS, CPT, HCPCS, and UB-04 specifications in effect at the time of service. If no specific CPT/HCPCS code exists, report the service using the appropriate unlisted procedure or service code and include a special report.

Report ICD-10-CM and PCS to the highest level of specificity
Use current CPT, HCPCS, and UB-04 edition in effect at time of service
If no specific code exists, use an appropriate unlisted procedure/service code with special report

Prior Authorization

Conservative treatment requirement

Coverage requires that no equally effective and more conservative or less costly treatment is available statewide before authorization will be granted. Providers must document prior conservative management attempts when relevant (e.g., medical therapy for nasal obstruction, antibiotics for sinusitis).

Demonstrate that conservative treatments were tried and failed or are not appropriate
Provide documentation of prior medical management when applicable (e.g., trials of medications, duration, and outcomes)

Congenital craniofacial deformity causing functional impairment; reconstruction after malignancy/abscess/osteomyelitis; deformity from documented trauma within 18 months

Septoplasty

DefinitionProcedure involving only the septum to correct deformities of the nasal septum

Indications (examples)Septal deviation causing continuous nasal airway obstruction not responsive to medical therapy; recurrent sinusitis or epistaxis related to septal deformity; performed with cleft repair

Functional goalRestore nasal airway patency and resolve septum-related exacerbations

Septorhinoplasty

DefinitionCombined repairs to the external nasal skeleton and nasal septa to correct functional impairment affecting both structures

IndicationsCorrects congenital defects, damage from disease, surgery, or trauma when both external and septal structures contribute to impairment

Clinical effectMay improve breathing and address deformity involving both external pyramid and septum

Recurrent (sinusitis or epistaxis) — definition pointer

Definition pointerRecurrent sinusitis/epistaxis: defined as four or more episodes in a year

Documentation noteNumber of episodes must be documented and, when applicable, shown to be related to septal deformity and refractory to medical therapy

Use in criteriaThreshold used as a required criterion for septoplasty coverage (see subsection 3.2.1.2)

Definitions section (relocated)

Change summaryDefinitions were moved into a list under 'Definitions' during the 04/01/2025 revision

LocationSee Definitions section for full term definitions (relocated from earlier sections)

Revision notePolicy header and Definitions relocation noted in Revision Information