CurrentEmblemHealthPolicy MG.MM.SU.08iC3

Medical Guideline Disclaimer

Defines EmblemHealth's clinical criteria for when rhinoplasty is considered medically necessary vs excluded, related applicable procedure and diagnosis codes, and revisions. Applies to coverage determinations and prior authorization review.

Policy Summary

PayerEmblemHealth

PolicyMedical Guideline Disclaimer

Policy CodePolicy MG.MM.SU.08iC3

Change TypeRevision history with added investigational language and covered indications

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the treatment or surgical procedure for prior authorization review.

SourceLink

POLICY UPDATE CHANGES

Removed photo documentation prerequisite (Feb. 10, 2023).

Eliminated prerequisite for nasal trauma/injury to have occurred within 18-months of surgical request; removed prerequisite for documentation at time of trauma; removed 'from large septal perforation' as an etiology descriptor for saddle nose deformity (Sept. 10, 2021).

Added investigational language for absorbable nasal implants to Limitations/Exclusions (Jun. 1, 2021).

Added nasal dermoid, saddle nose deformity and vestibular stenosis as covered indications (Mar. 13, 2020).

8Covered etiologies listed

2Primary exclusion categories

1Investigational procedure listed

Coverage Summary

Policy metadata

Policy numberMG.MM.SU.08iC3

PayerEmblemHealth

Policy title / subjectRhinoplasty medical necessity criteria

StatusCURRENT

Last review2023-02-10

Scope summaryDefines EmblemHealth's clinical criteria for when rhinoplasty is medically necessary vs excluded, related applicable procedure and diagnosis codes, and revisions; applies to coverage determinations and prior authorization review.

EmblemHealth's clinical review criteria are used to determine whether services are medically necessary; however, coverage for a service depends on each benefit program and applicable legal mandates. Treating physicians or primary care providers must submit clinical evidence that the patient meets the criteria for the requested treatment or procedure for prior authorization review.

Definition: Rhinoplasty — a surgical procedure of the nose to correct external nasal deformity while maintaining, restoring or improving nasal function.

Medical-Necessity Criteria

Medically Necessary - Rhinoplasty

Members are eligible for rhinoplasty when either of the following criteria is met:

ANY of the following

Performed in conjunction with a septoplasty for nasal airway obstruction when the nasal deformity contributes to the airway obstruction and septoplasty criteria are met.
ALL of the following
- Obstructive breathing etiologies (any one):
  - Excision of a nasal abscess.
  - Excision of a malignant mass.
  - Osteomyelitis.
  - Cleft lip and/or palate repair.
  - Nasal trauma or injury that resulted in significant deviation of the nasal pyramid or a creation of a significant dorsal hump.
  - Nasal dermoid.
  - Saddle nose deformity from surgery, trauma, or disease (Granulomatosis with Polyangiitis).
  - Vestibular stenosis for prolonged nasal obstruction which is moderate to severe, separate from obstruction caused by deviated septum or turbinate hypertrophy.

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Not Medically Necessary / Exclusions

Rhinoplasty is not covered when any of the following are applicable:

ALL of the following

Excluded indications (any one):
- Performed solely to change appearance in the absence of any signs or symptoms of functional abnormalities or nasal defects (cosmetic).
- For treatment of polyps not causing severe deformity.
Absorbable nasal implants for the treatment of nasal valve collapse (e.g., Latera Absorbable Nasal Implant, CPT 30468) are considered investigational for Commercial and Medicaid.

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Coding

Applicable CPT / Procedure CodesCPTCovered

30124	Excision dermoid cyst, nose; simple, skin, subcutaneous.
30125	Excision dermoid cyst, nose; complex, under bone or cartilage.
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.

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Investigational / Not Covered Procedure ExampleCPTExperimental

30468

Absorbable nasal implant (e.g., Latera) - considered investigational for Commercial and Medicaid.

Applicable Diagnosis Codes (Malignant / Neoplasm / Related)ICD-10Covered

C11.3	Malignant neoplasm of anterior wall of nasopharynx.
C30.0	Malignant neoplasm of nasal cavity.
C43.31	Malignant melanoma of nose.
C44.311	Basal cell carcinoma of skin of nose.
C44.321	Squamous cell carcinoma of skin of nose.
C44.391	Other specified malignant neoplasm of skin of nose.
D14.0	Benign neoplasm of middle ear, nasal cavity and accessory sinuses.
D38.5	Neoplasm of uncertain behavior of other respiratory organs.
D49.1	Neoplasm of unspecified behavior of respiratory system.

Applicable Diagnosis Codes (Nasal Disorders / Trauma / Congenital / Osteomyelitis)ICD-10Covered

J34.0	Abscess, furuncle and carbuncle of nose.
J34.1	Cyst and mucocele of nose and nasal sinus.
J34.89	Other specified disorders of nose and nasal sinuses.
J34.9	Unspecified disorder of nose and nasal sinuses.
M86.68	Other chronic osteomyelitis, other site.
M86.8X8	Other osteomyelitis, other site.
M95.0	Acquired deformity of nose.
Q30.1	Agenesis and underdevelopment of nose.
Q30.2	Fissured, notched and cleft nose.
Q30.3	Congenital perforated nasal septum.

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Provider Actions

Prior Authorization

Submit clinical evidence for prior authorization

Treating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the treatment or surgical procedure; without this documentation EmblemHealth will not be able to properly review the request for prior authorization.

Documentation Required

Document obstructive breathing symptoms and etiology

For reconstruction indications, document obstructive breathing symptoms and the specific etiology to meet criteria. Accepted etiologies include: excision of a nasal abscess; excision of a malignant mass; osteomyelitis; cleft lip and/or palate repair; nasal trauma or injury that resulted in significant deviation of the nasal pyramid or creation of a significant dorsal hump; nasal dermoid; saddle nose deformity from surgery, trauma, or disease (e.g., Granulomatosis with Polyangiitis); and vestibular stenosis causing prolonged moderate-to-severe obstruction separate from septal deviation or turbinate hypertrophy.

Excision of a nasal abscess
Excision of a malignant mass
Osteomyelitis
Cleft lip and/or palate repair
Nasal trauma/injury with significant deviation or dorsal hump
Nasal dermoid
Saddle nose deformity (surgery, trauma, or disease)
Vestibular stenosis causing prolonged moderate-to-severe obstruction

Billing Rule

Investigational device/procedure reporting

Absorbable nasal implants for the treatment of nasal valve collapse (e.g., Latera) are considered investigational for Commercial and Medicaid; do not expect coverage and billing for these devices/procedures may be denied.

CPT 30468 (Absorbable nasal implant, e.g., Latera)

Background & Evidence

This guideline provides clinical review criteria to determine when rhinoplasty is medically necessary and how it relates to EmblemHealth's Cosmetic and Reconstructive Surgery Procedures policy. It outlines reconstructive indications and exclusions to distinguish functional/reconstructive procedures from purely cosmetic rhinoplasty.

Rhinoplasty is defined as: a surgical procedure of the nose to correct external nasal deformity while maintaining, restoring or improving nasal function.

Sources referenced: Cummings-Otolaryngology Head and Neck Surgery April 2021; AAO-HNS Clinical Indicators; specialty-matched clinical peer review.

Revision History

2021-06-01added

Added investigational language for absorbable nasal implants to Limitations/Exclusions

2020-03-13added

Added nasal dermoid, saddle nose deformity and vestibular stenosis as covered indications

2021-09-10revised

2023-02-10removedLatest

Removed photo documentation prerequisite

Policy Summary

PayerEmblemHealth

PolicyMedical Guideline Disclaimer

Policy CodePolicy MG.MM.SU.08iC3

Change TypeRevision history with added investigational language and covered indications

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the treatment or surgical procedure for prior authorization review.

SourceLink

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