CurrentMassachusetts Executive Office of Health and Human ServicesPolicy MNG-RH-SE_2025-01

Guidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty

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This policy governs MassHealth medical-necessity determinations and prior authorization for rhinoplasty, septoplasty, and extracorporeal septoplasty for MassHealth members and enrolled surgeons.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty

Policy CodePolicy MNG-RH-SE_2025-01

Change TypeNo material clinical or coverage change

Effective DateDec 12, 2022

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically through the Provider Online Service Center with supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8Clinical indications for medically necessary septoplasty

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy MNG-RH-SE_2025-01

Guidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty

Customize your policy alerts

Sign up for Massachusetts Executive Office of Health and Human Services Policy MNG-RH-SE_2025-01 alerts

Get alerted when Policy MNG-RH-SE_2025-01 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs MassHealth medical-necessity determinations and prior authorization for rhinoplasty, septoplasty, and extracorporeal septoplasty for MassHealth members and enrolled surgeons.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty

Policy CodePolicy MNG-RH-SE_2025-01

Change TypeNo material clinical or coverage change

Effective DateDec 12, 2022

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically through the Provider Online Service Center with supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8Clinical indications for medically necessary septoplasty

Prior authorization for rhinoplasty and septoplasty

3 episodes/12 monthsRecurrent sinusitis threshold

4+ weeksRequired therapy for specified obstruction criteria

4 viewsPreoperative photographic views when required

2Procedures addressed

Medical Necessity and Coverage Criteria

Medically necessary septoplasty

Septoplasty is medically necessary when ANY one of the following criteria is met.

Septoplasty medical necessity

An asymptomatic septal deformity prevents access to other intranasal areas when that access is required to perform a medically necessary surgical procedure, such as an ethmoidectomy.
B: Documented recurrent sinusitis is thought to be due to a deviated septum and has not been relieved by appropriate medical and antibiotic therapy.Minimum of 3 episodes over a 12-month period
C: Nasal septum trauma resulted in significant functional deformity that was not present before the injury.
D: Reconstruction is needed after removal of a tumor, nasal polyps, or part of the ethmoid bone.
E: The patient has obstructive sleep apnea and difficulty tolerating CPAP because of significant nasal obstruction unresponsive to conservative management, and septoplasty is being performed to enhance CPAP or BiPAP effectiveness.
F: Recurrent epistaxis is thought to be related to an underlying septal deformity.
G: Septal deviation causes continuous nasal airway obstruction and difficulty breathing through the nasal passages despite appropriate medical therapy.At least 4 weeks of appropriate medical therapy
H: Septoplasty is performed in association with cleft lip or palate repair.

Extracorporeal septoplasty

Extracorporeal septoplasty is medically necessary only for initial correction when the member also meets septoplasty criteria.

Initial extracorporeal septoplasty

The nasal septum is extremely deviated and cannot be adequately corrected with an intranasal approach.
The member meets the clinical criteria for medically necessary septoplasty.

Limited medically necessary rhinoplasty

Rhinoplasty may be medically necessary in the following limited circumstances.

Rhinoplasty limited indications

A: Rhinoplasty is performed to correct a nasal deformity secondary to congenital cleft lip and/or palate or for removal of a nasal dermoid.
Photographic evidence of the anatomical abnormality must be provided.
B
- B1–B8
  - The airway obstruction will not respond to turbinectomy and septoplasty alone.
  - Functional impairment is expected to be resolved by rhinoplasty.

Experimental and investigational indications

The following services or indications are considered experimental and investigational.

Experimental or investigational indications

Septoplasty is requested for an indication outside the listed medically necessary criteria, such as allergic rhinitis.
Extracorporeal septoplasty is requested for revision of a deviated septum.
Rhinoplasty is requested for an indication outside the listed limited circumstances, including repair of nasal valve collapse, use of an absorbable nasal implant, concentrated growth factor for a septal mucosal defect following rhinoplasty, septal swell-body treatment for chronic rhinitis, chronic sinusitis, or nasal pyriform aperture reduction (pyriform turbinoplasty) for nasal obstruction.

Cosmetic-only rhinoplasty and/or septoplasty performed solely to enhance appearance are not covered by MassHealth. Coverage is directed to reconstructive or functional treatment supported by the policy’s medical-necessity criteria.

Septoplasty for indications other than the listed clinical criteria is considered experimental and investigational. This includes septoplasty performed for allergic rhinitis, for which the policy states that authoritative evidence of clinical efficacy is lacking.

Extracorporeal septoplasty for revision of a deviated septum is considered experimental and investigational. Medically necessary extracorporeal septoplasty is limited to initial correction of an extremely deviated septum that cannot be adequately corrected through an intranasal approach when the member also meets the policy’s septoplasty criteria.

Rhinoplasty for indications outside the policy’s limited medically necessary circumstances is considered experimental and investigational. Examples include nasal valve-collapse repair, absorbable nasal implants, concentrated growth factor for septal mucosal defects, septal swell-body treatment for chronic rhinitis, chronic sinusitis, and pyriform turbinoplasty for nasal obstruction.

Thresholds and Coding-Related Parameters

Recurrent sinusitis threshold

Minimum frequencyAt least 3 documented episodes

Time periodOver a 12-month period

Related indicationRecurrent sinusitis thought to be due to a deviated septum

Treatment responseNot relieved by appropriate medical and antibiotic therapy

Conservative or medical therapy

Required durationFour or more weeks

Applies toSpecified nasal obstruction indications

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for rhinoplasty and septoplasty. MassHealth reviews requests for medical necessity, and the MassHealth-enrolled surgeon performing the procedure must submit the request with supporting clinical documentation; approval remains subject to member eligibility, other insurance, and applicable program restrictions.

Submit documentation supporting medical necessity, including the assessment and surgical referral from qualified licensed health professional(s).

Prior Authorization

Submit PA Electronically

Providers must electronically submit PA requests and all supporting documentation through the Provider Online Service Center (POSC).

If the provider has a currently approved electronic claims waiver, submit the MassHealth PA-1 Form and all supporting documentation instead.
For POSC access questions, contact the MassHealth Customer Service Center at (800) 841-2900; TDD/TTY: 711.

Clinical Context

Reconstructive rhinoplasty corrects an external nasal deformity or damaged nasal structures, or replaces lost tissue, while maintaining or improving the nose’s physiological function. Reconstructive treatment is intended to restore or preserve nasal function; any cosmetic enhancement is incidental rather than the sole purpose of the procedure.

Key Terms

Reconstructive rhinoplasty

ProcedureSurgery of the nose

PurposeCorrects an external nasal deformity or damaged nasal structures, or replaces lost tissue

Functional objectiveMaintains or improves the physiological function of the nose

Reconstructive septoplasty

ProcedureSurgical correction of defects and deformities of the nasal septum

Corrective methodsAltering, splinting, or removing obstructive tissue

Functional objectiveMaintains or improves the physiological function of the nose

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty

Policy CodePolicy MNG-RH-SE_2025-01

Change TypeNo material clinical or coverage change

Effective DateDec 12, 2022

Next Review DateN/A

Key ActionSubmit prior authorization requests electronically through the Provider Online Service Center with supporting clinical documentation.

SourceLink

On This Page

Nasal airway obstruction is causing significant symptoms, such as difficulty breathing or chronic rhinosinusitis.

Obstructive symptoms persist despite conservative management, including nasal steroids or immunotherapy when appropriate.At least 4 weeks or more of conservative management when appropriate

Nasal breathing is persistently and prolongedly obstructed.

Photographs demonstrate an external nasal deformity.

Physical examination confirms moderate to severe vestibular obstruction.

CT, nasal endoscopy, or another appropriate imaging modality documents significant obstruction of one or both nares.

C: Rhinoplasty for nasal airway obstruction is performed as a component of medically necessary septoplasty, and gross nasal obstruction is documented on the same side as the septal deviation.

D: There is severe deformity and difficulty breathing related to inflammatory disease, abscess, or osteomyelitis, or following removal of nasal malignancy that caused difficulty breathing and severe deformity.

Examples of inflammatory disease include pleomorphic granulomatosis and granulomatosis with polyangiitis.

Septoplasty indicationContinuous nasal airway obstruction causing difficulty breathing despite appropriate medical therapy

Vestibular stenosis indicationObstructive symptoms persisting despite conservative management for at least four weeks or more

Documentation Required

Medical History and Clinical Assessment

Document the patient’s relevant medical history and the qualified provider’s clinical assessment supporting the proposed procedure. The surgeon’s submission must include the required history and the assessment and referral from qualified licensed health professional(s).

History may include an asymptomatic deformity preventing surgical access; atypical facial pain of nasal origin; frequent nosebleeds; or nasal airway obstruction/difficult nasal breathing causing mouth breathing, snoring, sleep apnea, or recurrent sinus infections.
For atypical facial pain, a positive response to topical anesthetic when a deformed septum contacts a turbinate supports, but does not prove, a septal cause.
Document relevant trauma, congenital defect, disease, symptom duration and severity, and response to conservative management when applicable.

Documentation Required

Physical Examination Findings

When appropriate, provide complete examination findings supporting the indication for surgery, including the required nasal and upper-airway assessments.

Describe the complete anterior and posterior nasal examination.
If surgery is intended to prevent sleep apnea or snoring, describe the nasopharynx, oropharynx, hypopharynx, and larynx.
Document the absence of nasal polyps, tumors, turbinate hypertrophy, or other causes of obstruction unless removal is part of the proposed surgery.
For epistaxis, identify the known or suspected bleeding site; for recurrent sinus disease, identify the recurrently infected sinus.

Documentation Required

Functional Rhinoplasty Supporting Records

For functional rhinoplasty, provide records showing that the nasal obstruction is clinically significant, functionally impairing, persistent despite appropriate conservative treatment, and supported by examination and objective findings.

For vestibular stenosis, document obstruction that will not respond to turbinectomy and septoplasty alone, expected functional improvement from rhinoplasty, significant symptoms, and persistent/prolonged obstructed nasal breathing.
Document the duration and degree of symptoms, such as chronic rhinosinusitis or mouth breathing, and the response to conservative management for at least four weeks when applicable, including nasal steroids or immunotherapy.
Include relevant history of accidental or surgical trauma, congenital defect, or disease, and results of nasal endoscopy, CT, or other appropriate imaging documenting the degree of obstruction.
Document moderate to severe vestibular obstruction on physical examination and significant obstruction of one or both nares when vestibular stenosis is the indication.

Documentation Required

Preoperative Photographs

Submit preoperative photographs when required to demonstrate the external nasal abnormality or functional deformity supporting coverage.

For rhinoplasty correcting a deformity secondary to congenital cleft lip and/or palate or removal of a nasal dermoid, provide photographic evidence of the anatomical abnormality.
For vestibular stenosis or rhinoplasty performed with medically necessary septoplasty when an external deformity is present, provide the standard four-way views: anterior-posterior, right lateral, left lateral, and nasal base (worm’s-eye) views.
The nasal-base view should confirm vestibular stenosis by viewing from below the nasal septum upward.

Documentation Required

Objective Testing

Objective testing is not universally required for septoplasty assessment, but submit available testing when it supports the indication or is required to document functional rhinoplasty criteria.

AAOHNS states that objective testing, such as CT, is optional in assessing the need for septoplasty.
For vestibular stenosis or related functional rhinoplasty criteria, include nasal endoscopy, CT, or other appropriate imaging documenting the degree of nasal obstruction.

Denial Risk

Cosmetic-Only Surgery Is Not Covered

Cosmetic rhinoplasty and/or septoplasty performed solely to enhance appearance is not covered by MassHealth.

Any cosmetic enhancement must be incidental to a covered reconstructive or functional procedure, not the sole purpose of surgery.

Denial Risk

Septoplasty Indication Outside Criteria

MassHealth considers septoplasty experimental and investigational for indications outside the listed clinical criteria because authoritative evidence is lacking.

Examples include allergic rhinitis.
Covered indications include qualifying access to other intranasal areas, recurrent sinusitis attributable to deviation despite appropriate therapy, traumatic functional deformity, reconstruction after specified tissue removal, CPAP/BiPAP intolerance caused by unresponsive nasal obstruction, recurrent epistaxis related to deformity, continuous obstruction despite four or more weeks of appropriate medical therapy, and cleft lip or palate repair.

Denial Risk

Revision Extracorporeal Septoplasty

Extracorporeal septoplasty for revision of a deviated septum is considered experimental and investigational and is not supported as a covered indication.

Extracorporeal septoplasty may be medically necessary for initial correction of an extremely deviated septum that cannot be adequately corrected intranasally when the member otherwise meets septoplasty criteria.
Revision of a deviated septum is not included in that medically necessary indication.

Denial Risk

Rhinoplasty Indication Outside Criteria

Rhinoplasty may be considered medically necessary only in the limited circumstances identified by MassHealth. Other indications are considered experimental and investigational.

Limited circumstances include qualifying congenital cleft lip/palate or nasal dermoid deformity; qualifying chronic non-septal obstruction from vestibular stenosis; rhinoplasty performed as a component of medically necessary septoplasty with gross obstruction on the same side; and severe deformity with breathing difficulty associated with specified disease, abscess, osteomyelitis, or removal of nasal malignancy.
Examples of other experimental and investigational indications include nasal valve collapse repair, absorbable nasal implants, concentrated growth factor for septal mucosal defects, septal swell bodies for chronic rhinitis, chronic sinusitis, and pyriform turbinoplasty for nasal obstruction.

Documentation Required

Complete Functional Rhinoplasty Documentation

Insufficient documentation of functional impairment, persistent obstruction, or supporting findings may prevent approval for functional rhinoplasty. For vestibular stenosis and rhinoplasty performed with septoplasty, submit the complete evidence required by the applicable criteria.

Document symptom duration and degree, functional impairment, and response to at least four weeks of conservative management when applicable.
Provide relevant trauma, congenital-defect, or disease history; physical examination confirming moderate to severe vestibular obstruction; and CT, nasal endoscopy, or other appropriate imaging documenting obstruction.
Include required four-way preoperative photographs when an external nasal deformity is present.
For rhinoplasty performed with septoplasty, document gross nasal obstruction on the same side as the septal deviation.

Anatomic siteThe nasal septum, the partition between the nostrils

Vestibular stenosis

DefinitionNon-septal nasal airway obstruction caused by collapsed internal nasal valves

Anatomic sourceCollapsed internal nasal valves

Type of obstructionChronic non-septal nasal airway obstruction

Potential causesCongenital defect, trauma, or disease