CurrentColorado Rocky Mountain Health PlansPolicy CS107OH.C

Rhinoplasty and Other Nasal Procedures (for Ohio Only)

Defines medical necessity, reconstructive vs cosmetic determinations, and unproven/not medically necessary nasal procedures for members of Colorado Rocky Mountain Health Plans applicable only to Ohio. Includes criteria for nasal valve procedures, rhinophyma excision, nasal polypectomy (via InterQual), rhinoplasty (age-stratified), and lists applicable CPT/HCPCS codes plus definitions and evidence summary.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyRhinoplasty and Other Nasal Procedures (for Ohio Only)

Policy CodePolicy CS107OH.C

Change TypeRemoved and Revised (06/01/2025)

Effective DateJun 1, 2025

Next Review Date

Key ActionProvide photos and clinical documentation showing dynamic collapse or anatomic deformities as the primary cause of Mechanical Nasal Airway Obstruction and include a clear surgical plan including need for cartilage graft.

POLICY UPDATE CHANGES

Removed CPT code 30999 from applicable codes (effective 06/01/2025).

Updated Description of Services, Clinical Evidence, and References sections; previous policy CS107OH.B archived.

4Main covered procedure groups (nasal valve repair, rhinophyma excision, nasal polypectomy, rhinoplasty)

4Explicitly listed unproven procedures

~20CPT/HCPCS codes listed

24 mo

Coverage Summary

This policy (Policy Number CS107OH.C) is effective June 1, 2025 and applies only to the state of Ohio. It differentiates reconstructive (medically necessary) procedures from cosmetic procedures and lists the main covered/referenced procedure groups: nasal valve procedures/repair of nasal vestibular stenosis or alar collapse, rhinophyma excision, nasal polypectomy (criteria via InterQual), and rhinoplasty (age‑stratified criteria). The Summary of Changes effective 06/01/2025 removed CPT code 30999 from the applicable codes and archived the prior version (CS107OH.B).

Thresholds and scope highlights

Conservative management durationsRhinoplasty indications/revisions/tip: symptoms persist despite conservative management >=4 weeks; 'Prolonged, Persistent Nasal Airway Obstruction' defined as failure of 6 weeks of medical management (eg, nasal steroids, antihistamines, decongestants)

Responder thresholds (NOSE)Responder often defined as >=20% improvement or >=1 NOSE severity class improvement (policy definitions and trial endpoints)

Responder thresholds (rTNSS/TNSS)>=30% reduction from baseline commonly used as responder threshold in rTNSS/TNSS RCTs

Main covered procedure groups (count)4 main covered groups: nasal valve repair/vestibular stenosis/alar collapse, rhinophyma excision, nasal polypectomy (per InterQual), rhinoplasty (age-stratified)

Explicitly listed unproven procedures (count & examples)4 explicitly listed unproven/not medically necessary procedures: absorbable polylactic acid nasal cartilage implants (Latera), nasal septal swell body (NSB) reduction, PNN/SPG ablation (eg RhinAer, ClariFix), radiofrequency nasal valve treatment (VivAer)

Codes referenced (illustrative)Applicable CPT/HCPCS codes listed (~20) including 30400-30469, 30117, 30120, 31237, 31242, 31243; CPT 30999 removed effective 06/01/2025

Medical Necessity Criteria (grouped)

Unproven / Not Medically Necessary Procedures

Evidence Summary and Coverage Implications

This policy is specific to Ohio and notes that UnitedHealthcare uses InterQual for primary medical/surgical criteria (and may use its own policies if InterQual lacks applicable criteria). The policy distinguishes reconstructive (medically necessary) procedures (examples: nasal valve repair, rhinophyma excision, selected rhinoplasty indications) from procedures that are primarily cosmetic, and references InterQual for certain rhinoplasty and nasal polypectomy medical necessity determinations. It also identifies several procedures considered unproven / not medically necessary due to insufficient evidence.

Key evidence-level notes

Overall evidence quality noteMany device and procedure studies are single-arm, small, single-center or industry-sponsored; overall evidence quality is low to minimal and longer RCTs with long-term follow-up are needed

Latera (absorbable implant) RCT evidenceStolovitzky et al. RCT (137 randomized): treatment responder 82.5% vs sham 54.7% at 3 months; short-term follow-up; subsequent follow-up cohorts report durable improvements to 24 months (Bikhazi et al.)

PNN ablation RCTs and meta-analysesDel Signore 2022 cryotherapy RCT: 73.4% vs 36.5% responders at 90 days (>=30% rTNSS reduction); Stolovitzky 2021 TCRF RCT: responder 67.5% vs 41.0% at 3 months; systematic reviews/meta-analyses show symptom reductions but limited long-term data

Coding

Billing Rule

Code removal effective 06/01/2025

Code removal effective 06/01/2025: Do not bill CPT code 30999 for services rendered on or after 2025-06-01. Providers must update claims to use the appropriate CPT/HCPCS code(s) that describe the procedure performed.

Affected code: 30999
Effective date: 2025-06-01
Instruction: Providers must not bill 30999 after the effective date; use the specific, appropriate code(s) instead.

Provider Actions / Documentation & Prior Authorization

Prior Authorization

Prior authorization recommended for device/procedure coverage

Prior authorization is recommended for device-based or procedure coverage to verify appropriateness.

Verify medical refractoriness (e.g., symptoms persistent ≥6 months or as specified in study/criteria)
Confirm documented baseline validated symptom scores (NOSE, rTNSS/TNSS, etc.) per InterQual / policy requirements
Confirm prior conservative therapy (e.g., intranasal steroids ≥4–6 weeks, other maximal medical therapy)

Documentation Required

Reference federal/state/contractual requirements

When determining coverage, reference federal, state (Ohio Administrative Code), or contractual requirements that govern benefit coverage.

Definitions

Term	Definition
External Nasal Valve
The caudal septum, along with lower lateral cartilage, alar rim, and nostril sill contribute to the External Nasal Valve (Rohrich, 2009).
Mechanical Nasal Airway Obstruction
Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity (Corey, 2009).
Prolonged, Persistent Nasal Airway Obstruction
Trouble breathing through the nose that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants; excludes drug-induced rhinitis.
NOSE
Nasal Obstruction Symptom Evaluation score, disease-specific QOL instrument used to assess nasal obstruction severity.
rTNSS / TNSS
Reflective Total Nasal Symptom Score / Total Nasal Symptom Score — composite/validated patient-reported instrument for nasal/rhinitis symptoms; used to define responders (commonly >=30% reduction).
TCRF
Temperature-Controlled Radiofrequency — transmucosal radiofrequency treatment applied to target tissues (eg, septal swell body, PNN) used for neurolysis or nasal valve remodeling (e.g., RhinAer, VivAer).
NOSE Scale
Nasal Obstruction Symptom Evaluation — validated questionnaire for nasal airway obstruction; responder often defined as >=20% improvement or >=1 severity class improvement.

Medicare Determinations / Referenced Coverage

Type	Number	Name	Effective
LCD
L39462
Sacroiliac Joint Injections and Procedures
2023

Revision History

2025-06-01code_removedLatest

Material change (is_material true): Summary of Changes effective 06/01/2025 — Removed CPT code 30999 from applicable codes. Providers must not bill under CPT 30999 for services referenced by this policy after the effective date.

archived_version

Archived previous policy version CS107OH.B — Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.