CurrentAspirus ArisePolicy CP-AMCR24-004A

Septoplasty

Defines coverage for septoplasty and repair of vestibular stenosis for Aspirus Medicare Advantage products, excluding cleft lip/palate management and cosmetic rhinoplasty. Applies to outpatient surgery benefit.

Policy Summary

PayerAspirus Arise

PolicySeptoplasty

Policy CodePolicy CP-AMCR24-004A

Change TypeAnnual review (minor edits)

Effective DateAug 1, 2024

Next Review Date

Key ActionDocument deviated septum causing continuous nasal airway obstruction and resulting nasal breathing difficulty to support coverage for septoplasty.

SourceLink

POLICY UPDATE CHANGES

Annual Review performed on 10/08/2024 with minor edits and updated effective date and disclaimer.

Annual Review performed on 09/18/2025 with minor changes and updated year to 2026.

Original policy created with effective date 08/01/2024.

2Covered Indications (septoplasty; vestibular stenosis repair)

2Explicit Non-covered Procedures (cosmetic surgery; rhinoplasty alone)

2CPT codes listed

Coverage Summary

Policy Number CP-AMCR24-004A. This policy defines coverage for septoplasty and related procedures for Aspirus Medicare Advantage products (Aspirus Medicare Advantage Elite (PPO) and Aspirus Medicare Advantage Essential Rx (PPO)). Effective date: August 1, 2024; Last review date: September 18, 2025. Applies to the Outpatient Surgery benefit.

Coverage stance: Covered with criteria — septoplasty for a deviated septum and repair of vestibular stenosis are covered when the clinical criteria are met (see policy). Prior authorization is not required when the deviation causes continuous nasal airway obstruction resulting in nasal breathing difficulty.

Medical Necessity Criteria

Covered

Covered when ALL of the following are met:

ALL of the following

ALL of the following
- Procedure is septoplasty for a deviated septum
- Deviation causes continuous nasal airway obstruction resulting in nasal breathing difficulty
Repair of vestibular stenosis
- Repair of vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction) is performed

Not Covered / Exclusions

ANY of the following

Cosmetic surgery to improve or change appearance (other than reconstructive surgery) that is not necessary to treat a related illness or injury
Rhinoplasty (alone) to change the appearance of the nose

Provider Actions

Prior Authorization

Prior authorization not required

Prior authorization is not required for septoplasty or repair of vestibular stenosis when the deviation causes continuous nasal airway obstruction resulting in nasal breathing difficulty.

30520
30465

Documentation Required

Clinical indication documentation

Providers should document deviated septum causing continuous nasal airway obstruction and resulting nasal breathing difficulty to support coverage for septoplasty.

Background & Definitions

A deviated septum exists when the bone and cartilage of the nasal septum are out of alignment or crooked due to injury or deformity, blocking one or both nostrils and impairing breathing.

Septoplasty is the surgical correction of septal defects by altering, splinting, or removing obstructive tissue to maintain or improve nasal physiological function. Rhinoplasty changes the shape and appearance of the nose and may be performed for functional or cosmetic reasons. Septorhinoplasty combines septal repair with functional rhinoplasty primarily to improve breathing and correct deformities; appearance changes may occur but are not the primary purpose.

This policy excludes services related to the management of birth defects such as cleft lip or cleft palate repair. Cosmetic surgery performed solely to change appearance (rhinoplasty alone) is not covered.

Term	Definition
Deviated septum	When the bone and cartilage of the nasal septum is out of alignment/crooked due to an injury or deformity that blocks one or both nostrils and impairs breathing.
Septoplasty	Surgical correction of defects and deformities of the nasal septum (partition between the nostrils) by altering, splinting, or removing obstructive tissue while maintaining or improving the physiological function of the nose.
Rhinoplasty	Surgery that changes the shape of the nose and results in changes in the appearance of the nose; may be performed for functional or cosmetic reasons.
Septorhinoplasty	Repair of the nasal septum combined with functional rhinoplasty to correct breathing constriction issues; primary purpose is to improve breathing and correct deformities; changes in appearance may occur.

Revision History

2024-08-01added

Original policy created with effective date 08/01/2024 (V1: New policy Aspirus).

2024-10-08revised

Annual Review performed on 10/08/2024 with minor edits, updated effective date and updated disclaimer.

2025-09-18revisedLatest