Colorado Rocky Mountain HMP ENT Procedures Coverage Update

Coverage Criteria

Rhinoplasty Coverage Criteria

Rhinoplasty is considered reasonable and necessary when ALL of the following are met:

Rhinoplasty not reasonable and necessary: Procedure is NOT reasonable and necessary when performed solely to improve appearance in the absence of any signs and/or symptoms of functional abnormality OR when used as primary treatment for an obstructive sleep disorder.

Cosmetic-only and sleep disorder primary treatment exclusions.

Rhinoplasty tip as reconstructive: Tip rhinoplasty is considered reconstructive and medically necessary when ALL of the following are present: (1) prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction; (2) photographic documentation clearly demonstrates tip drop as the primary cause and is consistent with the clinical exam; (3) the proposed procedure is designed to correct the anatomic mechanical obstruction by lifting the nasal tip; (4) nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing); and (5) obstructive symptoms persist despite conservative management for >= 4 weeks, including where appropriate nasal steroids or immunotherapy.>= 4 weeks conservative management

Specific criteria for tip reconstruction; conservative management requirement.

Medical necessity overview (Reconstructive / Functional indications)

Covered when surgery is reconstructive to improve nasal airway function or to correct anomalies from congenital defects, trauma, or disease; cosmetic-only procedures are excluded.

Reconstructive or functional indication: Surgery is for reconstructive purposes: performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, tumors, or disease and intended to improve function; OR surgery is to improve nasal airway function (functional rhinoplasty, septoplasty, septorhinoplasty).

Supported by reconstructive definitions and specialty guidance (ASPS, AAO-HNS).

Exceptions to cosmetic exclusion: Cosmetic surgery exclusion does NOT apply when the procedure is required for prompt (as soon as medically feasible) repair of accidental injury OR when the procedure improves the functioning of a malformed body member.

From Cosmetic Surgery definition and Medicare Benefit Policy Manual guidance.

Procedures performed solely for cosmetic improvement without any accompanying functional abnormality are excluded from coverage. Cosmetic surgery and related expenses are not covered except in limited reconstructive circumstances (for example, when required for prompt repair of accidental injury or to improve function of a malformed body member).

Rhinoplasty performed only to improve appearance in the absence of signs or symptoms of functional impairment is not considered reasonable and necessary and will generally be denied.

Rhinoplasty that is designated as “Always Cosmetic” is excluded from coverage. Cosmetic procedures are only covered when required for the prompt (as soon as medically feasible) repair of an accidental injury or when the procedure is necessary to improve the functioning of a malformed body member.

The policy’s Applicable Codes section was updated to add a list of non‑covered diagnosis codes supporting the rhinoplasty (Always Cosmetic) designation; these code updates reflect the policy’s operational changes to coding and do not change the cosmetic exclusion principles.

An exception exists for reconstructive rhinoplasty required to restore function after trauma, congenital deformity, or disease—such functional/reconstructive indications are addressed separately and require appropriate documentation (e.g., photographs and clinical findings).

Benefit coverage is determined by the member’s specific benefit plan. In the event of a conflict, the member specific benefit plan document supersedes this policy. Providers should verify member benefits and contact the customer service number on the member ID card for plan‑specific coverage details.

Rhinoplasty performed solely for aesthetic enhancement — i.e., to reshape normal structures to improve appearance or self‑esteem — is classified as cosmetic and excluded from coverage. Coverage is limited to procedures that correct abnormal structures or restore nasal airway function caused by congenital defects, trauma, disease, or other pathology.

When rhinoplasty is proposed for functional reasons (for example, to relieve airway obstruction from tip drop, vestibular stenosis, or post‑traumatic deformity), documentation must demonstrate the functional impairment and, where required by the criteria, include photographic evidence and evidence of prior conservative management.

Cosmetic surgery is defined as surgery performed to reshape normal structures of the body to improve appearance and self‑esteem and is not medically necessary when sought for that purpose alone. Such procedures and related expenses are excluded unless they meet stated exceptions (prompt repair after accidental injury or improvement of a malformed body member).

Rhinoplasty that functions primarily as cosmetic surgery—without clinical signs/symptoms of functional abnormality—is therefore not medically necessary and excluded under this policy.

Coding — CPT and ICD-10

Balloon Sinus Ostial Dilation CPT CodesCPT

31295	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, transnasal or via canine fossa.
31296	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium.
31297	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); sphenoid sinus ostium.
31298	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia.
31299	Unlisted procedure, accessory sinuses.

FESS CPT CodesCPT

31240	Nasal/sinus endoscopy, surgical; with concha bullosa resection.
31253	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed.
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior).
31257	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy.
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus.
31287	Nasal/sinus endoscopy, surgical, with sphenoidotomy.
31288	Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus.

Intranasal Repair CPT Codes (may be cosmetic)CPT

30540	Repair choanal atresia; intranasal.
30545	Repair choanal atresia; transpalatine.
30620	Septal or other intranasal dermatoplasty (does not include obtaining graft).

Notemixed

These intranasal repair codes may be cosmetic; review is required to determine if considered cosmetic or reconstructive.

Radiofrequency nasal valve treatment CPTCPT

30469

Repair of nasal valve collapse with low energy, temperature-controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling.

Rhinophyma Excision CPTCPT

30120

Excision or surgical planing of skin of nose for rhinophyma.

Rhinoplasty CPT CodesCPT

30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip.
30420	Rhinoplasty, primary; including major septal repair.
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work).
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies).
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies).
30460	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only.
30462	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies.
30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s).

Septoplasty CPTCPT

30520

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft.

Vestibular Stenosis Repair CPTCPT

30465

Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction).

ICD-10 Codes (selected examples)ICD-10

Z40.89	Encounter for other prophylactic surgery.
Z40.9	Encounter for prophylactic surgery, unspecified.
Z41.1	Encounter for cosmetic surgery.
J32.0	Chronic maxillary sinusitis.
J32.1	Chronic frontal sinusitis.
J32.2	Chronic ethmoidal sinusitis.
J32.4	Chronic pansinusitis.
J34.2	Deviated nasal septum.
J34.8201	Internal nasal valve collapse, static.
J34.8202	Internal nasal valve collapse, dynamic.

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Rhinoplasty CPT Codes referencedCPT

30400	rhinoplasty CPT listed in policy
30410	rhinoplasty CPT listed in policy
30420	rhinoplasty CPT listed in policy
30430	rhinoplasty CPT listed in policy
30435	rhinoplasty CPT listed in policy
30450	rhinoplasty CPT listed in policy
30460	rhinoplasty CPT listed in policy
30462	rhinoplasty CPT listed in policy
30468	rhinoplasty CPT listed in policy

Non-covered Diagnosis Codes (Rhinoplasty — Always Cosmetic)ICD-10Not Covered

Z40.89	non-covered diagnosis code added
Z40.9	non-covered diagnosis code added
Z41.1	non-covered diagnosis code added
Z41.3	non-covered diagnosis code added
Z41.8	non-covered diagnosis code added
Z41.9	non-covered diagnosis code added

Additional Diagnosis Codes added for Rhinoplasty CPTsICD-10

C4A.31	added diagnosis code for specified rhinoplasty CPTs
C4A.39	added diagnosis code for specified rhinoplasty CPTs
Z85.820	added diagnosis code for specified rhinoplasty CPTs
Z85.821	added diagnosis code for specified rhinoplasty CPTs
Z85.828	added diagnosis code for specified rhinoplasty CPTs

Conservative management duration — rhinoplasty tip

Required duration>= 4 weeks of conservative management (including nasal steroids or immunotherapy where appropriate)

ContextApplies to rhinoplasty tip when considered reconstructive for persistent obstructive nasal breathing due to tip drop

Documentation evidenceObstructive symptoms must persist despite conservative management; photos and clinical exam must support tip drop as primary cause

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required. Providers should verify benefit plan–specific prior authorization requirements before scheduling services.

Prior authorization requirements vary by member plan and by whether a delegate manages utilization management.
Call the customer service number on the back of the member ID card or check the Administrative Guide to confirm authorization rules.

Prior Authorization

Follow Delegate Prior Authorization Rules

When a delegate (for example, a Medicare Advantage delegate managing utilization management) administers prior authorization, providers must follow the delegate's prior authorization rules and processes.

If a delegate manages utilization management for the member's plan, follow the delegate's submission, documentation, and authorization requirements.
Confirm whether UnitedHealthcare or a delegate is responsible for prior authorization for the specific member before submitting requests.

Definitions

Cosmetic Surgery — definition

DefinitionCosmetic Surgery is surgery performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.

Coverage implicationCosmetic surgery and related expenses are not covered except when required for prompt repair of accidental injury or to improve function of a malformed body member.

Reference guidanceRefer to Medicare Benefit Policy Manual, Chapter 16, §120 and CMS LCDs for additional detail.

Reconstructive Surgery — definition

DefinitionReconstructive Surgery is surgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, tumors, or disease.

PurposeGenerally performed to improve function and may also approximate normal appearance.

Background

This policy covers common ENT surgical interventions that address functional sinonasal disease and structural nasal deformities. It distinguishes reconstructive/functional indications—where surgery aims to improve nasal airway function or to correct anomalies from congenital defects, trauma, or disease—from cosmetic procedures, which are excluded except in limited exceptions (e.g., prompt repair after accidental injury or to improve a malformed body member).

For reconstructive or functional rhinoplasty, the policy requires objective documentation (including frontal, lateral, and worm’s‑eye photographs) and, for certain indications such as tip reconstruction, evidence that obstructive symptoms persist despite conservative management for >= 4 weeks (including nasal steroids or immunotherapy when appropriate).

Providers are expected to retain supporting clinical documentation and to confirm member‑specific benefit coverage; Medicare Advantage plan documents guide coverage determinations and the member’s benefit plan supersedes this policy when discrepancies exist.

OpenPayer

Ear, Nose, and Throat Procedures (Rhinoplasty and Other Nasal Procedures; Sinus Surgeries and Interventions)

Coverage Criteria

Coding — CPT and ICD-10

Provider Actions and Documentation Requirements

Definitions

Background