ModifiedPriority Health MedicarePolicy 91506-R8

Septoplasty / Rhinoplasty

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This policy governs when septoplasty and rhinoplasty may be considered medically necessary, including clinical criteria, documentation requirements, prior authorization, coding, exclusions, and experimental or unproven procedures.

Policy Summary

PayerPriority Health Medicare

PolicySeptoplasty / Rhinoplasty

Policy CodePolicy 91506-R8

Change TypeModified

Effective DateSep 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization for applicable rhinoplasty codes with documentation demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

Posterior nasal nerve ablation was deleted from this policy.

Policy scope and related policies were added.

4–6 weeksSeptoplasty therapy duration

3 months+Rhinoplasty conservative management

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ModifiedPriority Health MedicarePolicy 91506-R8

Septoplasty / Rhinoplasty

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Sign up for priority_health_medicare Policy 91506-R8 alerts

Get alerted when Policy 91506-R8 changes without checking for updates manually.

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Policy Summary

PayerPriority Health Medicare

PolicySeptoplasty / Rhinoplasty

Policy CodePolicy 91506-R8

Change TypeModified

Effective DateSep 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization for applicable rhinoplasty codes with documentation demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

Posterior nasal nerve ablation was deleted from this policy.

Policy scope and related policies were added.

4–6 weeksSeptoplasty therapy duration

3 months+Rhinoplasty conservative management

24 monthsTrauma correction period

30520Septoplasty code

Medical Necessity and Coverage Criteria

Medically Necessary Septoplasty

Septoplasty may be considered medically necessary when ANY of the following clinical criteria are met:

ANY of the following

Septal deviation causes continuous nasal airway obstruction resulting in nasal breathing difficulty that has not responded to 4 to 6 weeks of appropriate medical therapy.
Documented recurrent sinusitis is felt to be due to a deviated septum and has not been relieved by appropriate medical and antibiotic therapy.
Recurrent epistaxis is related to a septal deformity.
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.
Septoplasty is performed in association with cleft palate repair.

Medically Necessary Rhinoplasty

Rhinoplasty is generally cosmetic and not a covered benefit. It may be considered medically necessary and covered when the Primary Care Physician and/or consulting specialty physician documents ANY of the following qualifying pathways:

ANY qualifying pathway

Rhinoplasty corrects a nasal deformity secondary to congenital cleft lip and/or palate in a patient under age 18.
ALL of the following
- Rhinoplasty corrects chronic nasal airway obstruction due to trauma, disease, or a congenital defect.
- Nasal airway obstruction causes significant symptoms, such as chronic rhinosinusitis or difficulty breathing.
- Preoperative photographs demonstrate an external nasal deformity.

The following procedures are normally not covered: alar tip cartilage repair, dorsal hump removal, shortening of the nasal septum, narrowing of the bony pyramid, nasal tip reconstruction, and saddle nose deformity. Coverage may be provided on an individual-consideration basis by the Medical Director when documentation substantiates that one or more of these procedures is required to correct a functional nasal airway obstruction. For cases of trauma, treatment to correct an accidental injury must occur within 24 months from the date of injury. Exceptions to this timeframe require prior approval by the Medical Director and may be approved when documentation establishes sufficient medical justification for the delay.

Cosmetic rhinoplasty is not a covered benefit. Rhinoplasty is covered only when the applicable medical-necessity criteria and documentation requirements are met.

Repair of nasal valve collapse or vestibular lateral wall stenosis with absorbable nasal implants, such as Latera®, is considered experimental, investigational, and/or unproven. Repair of nasal valve collapse with low-energy, temperature-controlled radiofrequency subcutaneous or submucosal remodeling, such as VivAer®, is not medically necessary because this method or device is not superior to or more beneficial than other standard treatments.

Coding and Coverage Status

ICD-10 Codes That May Support Medical NecessityICD-10

C30.0	Malignant neoplasm of nasal cavity
C41.0	Malignant neoplasm of bones of skull and face
C44.300-C44.399	Other and unspecified malignant neoplasm of skin of other and unspecified parts of face
C76.0	Malignant neoplasm of head, face and neck
D03.30	Melanoma in situ of unspecified part of face
D04.39	Carcinoma in situ of skin of other parts of face
D14.0	Benign neoplasm of middle ear, nasal cavity and accessory sinuses
D16.4	Benign neoplasm of bones of skull and face
D22.30-D22.39	Melanocytic nevi of other part of face
D38.5	Neoplasm of uncertain behavior of other respiratory organs

1–10 of 29

1/3

CPT/HCPCS CodesCPTCovered

30520

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

Prior Authorization Required Rhinoplasty CodesCPTCovered

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

Not CoveredCPTNot Covered

30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) (Covered for Medicaid and Medicare)
30469	Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling; includes VivAer (Aerin Medical Inc.) (Covered for Medicaid and Medicare)
31242	Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve; includes RhinAer (Aerin Medical Inc.) (Covered for Medicaid and Medicare)
31243	Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve; includes ClariFix (Stryker) (Covered for Medicaid and Medicare)

Septoplasty medical-therapy failure

Required duration4 to 6 weeks of appropriate medical therapy

Applies toContinuous nasal airway obstruction caused by septal deviation

Coverage conditionNasal breathing difficulty must not respond to the appropriate medical therapy

Rhinoplasty conservative-management failure

Required durationThree months or greater

Applies toObstructive symptoms related to medically necessary rhinoplasty

Authorization and Documentation Requirements

Prior Authorization

Rhinoplasty Prior Authorization Required

Prior authorization is required for the listed rhinoplasty services. Coverage limitations may apply by individual plan, including noncoverage of codes 30400–30410 and 30430–30462 for certain plans.

30400 — Primary rhinoplasty; lateral and alar cartilages and/or elevation of nasal tip
30410 — Primary rhinoplasty; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420 — Primary rhinoplasty, including major septal repair
30430 — Secondary rhinoplasty; minor revision
30435 — Secondary rhinoplasty; intermediate revision
30450 — Secondary rhinoplasty; major revision
30460 — Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate; tip only
30462 — Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate; tip, septum, osteotomies
Refer to the Priority Health Provider Manual for current authorization requirements and plan-specific limitations.

Clinical Background

Septal deviation is a common structural cause of nasal obstruction. Septoplasty is generally performed to improve nasal breathing and quality of life, and may also be used for recurrent epistaxis, recurrent sinusitis related to a deviated septum, access for other medically necessary intranasal surgery, or in association with cleft palate repair.

Definitions

Rhinoplasty

DefinitionA surgical operation on the nose that alters the nasal skin, underlying cartilage, and bone

ApplicationsMay be reconstructive, restorative, or cosmetic in nature

Potential resultsCan change nasal size, tip or bridge shape, nostril width, or the angle between the nose and upper lip, and may correct a birth defect or injury or help relieve breathing problems caused by obstruction

VivAer

Procedure settingA noninvasive, office-based procedure intended as an alternative to invasive surgical intervention

Treatment methodUses low-dose nonablative radiofrequency energy to modify nasal-airway soft tissue

Policy Summary

PayerPriority Health Medicare

PolicySeptoplasty / Rhinoplasty

Policy CodePolicy 91506-R8

Change TypeModified

Effective DateSep 1, 2026

Last ReviewAug 1, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization for applicable rhinoplasty codes with documentation demonstrating medical necessity.

SourceLink

On This Page

Obstructive symptoms persist despite conservative management for three months or greater, including nasal steroids or immunotherapy where appropriate.

The airway obstruction will not respond to septoplasty and turbinectomy alone.

There is documentation of gross nasal obstruction on the same side as the septal deviation.

Rhinoplasty is an integral part of a coordinated surgical procedure, with a medically necessary septoplasty, to restore function.

Documentation includes relevant history of accidental or surgical trauma, congenital defect, or disease, such as Wegener's granulomatosis, choanal atresia, nasal malignancy, abscess, septal infection with saddle deformity, or congenital deformity.

Documentation describes the duration and degree of symptoms related to nasal obstruction, such as chronic rhinosinusitis or mouth breathing, and the results of conservative management.

Conservative managementIncludes nasal steroids or immunotherapy where appropriate

Accidental injury treatment period

Required treatment periodWithin 24 months from the date of the accidental injury

Exception approvalExceptions must be approved in advance by the Medical Director

Exception documentationThe documentation must establish sufficient medical justification for the delay

Documentation Required

Submit Medical-Necessity Documentation

When prior authorization is required, providers must submit a request demonstrating that the service or procedure is medically necessary. Refer to the Priority Health Provider Manual for additional authorization instructions.

Submit clinical documentation supporting the medical necessity of the requested rhinoplasty or related service.
Include the applicable symptoms, diagnoses, treatment history, examination findings, photographs, and operative rationale.

Documentation Required

Document Septoplasty Criteria and Conservative-Treatment Failure

For septoplasty, document the applicable clinical indication and failure of required conservative treatment when obstruction or sinusitis is the basis for surgery.

Continuous nasal airway obstruction causing difficulty breathing that did not respond to 4 to 6 weeks of appropriate medical therapy.
Recurrent sinusitis attributed to a deviated septum that was not relieved by appropriate medical and antibiotic therapy.
Recurrent epistaxis related to a septal deformity.
An asymptomatic septal deformity preventing access to another intranasal area needed for a medically necessary procedure, such as an ethmoidectomy.
Septoplasty performed in association with cleft palate repair.

Documentation Required

Document Rhinoplasty Conservative-Treatment Failure

For functional rhinoplasty based on chronic nasal airway obstruction, document persistent obstructive symptoms despite conservative management for at least three months.

Document appropriate conservative treatment, including nasal steroids or immunotherapy when applicable.
Show that symptoms remain significant despite treatment, such as chronic rhinosinusitis or difficulty breathing.
Document that the obstruction will not respond to septoplasty and turbinectomy alone and that rhinoplasty is integral to a coordinated medically necessary septoplasty procedure.

Unsupported block type: documentation

Documentation Required

Document Etiology and Clinical History

Document the underlying etiology of the nasal deformity or obstruction and the relevant clinical history supporting the requested procedure.

Relevant accidental or surgical trauma
Congenital defect, including congenital deformity or cleft lip and/or palate
Disease-related cause, such as Wegener's granulomatosis, choanal atresia, nasal malignancy, abscess, or septal infection with saddle deformity
Clinical history linking the etiology to the nasal obstruction or deformity

Documentation Required

Document Symptoms and Conservative Treatment

The record must describe the duration and degree of nasal-obstruction symptoms and the conservative management provided and its results.

Document symptom duration and severity, including chronic rhinosinusitis, mouth breathing, or difficulty breathing.
Describe the conservative treatments provided and the patient's response.
For functional rhinoplasty, document persistent symptoms despite conservative management for three months or greater.

Documentation Required

Support Functional Rhinoplasty Medical Necessity

Functional rhinoplasty requires records supporting significant obstruction, the associated external deformity, persistence of symptoms, and the need for rhinoplasty in addition to septoplasty.

Document chronic nasal airway obstruction causing significant symptoms.
Provide photographs demonstrating the external nasal deformity when present.
Show persistent obstructive symptoms despite at least three months of appropriate conservative management.
Document gross nasal obstruction on the same side as the septal deviation.
Document that septoplasty and turbinectomy alone will not correct the obstruction and that rhinoplasty is part of a coordinated procedure with medically necessary septoplasty.

Documentation Required

Document Trauma Timing or Approved Exception

For accidental trauma, treatment to correct the injury must occur within 24 months of the injury date unless the Medical Director approves an exception in advance.

Document the date of injury and that treatment occurs within the 24-month period.
If treatment is delayed beyond 24 months, obtain prior Medical Director approval.
Support an exception with documentation establishing sufficient medical justification for the delay.

Denial Risk

Cosmetic or Insufficiently Supported Rhinoplasty

Rhinoplasty is generally cosmetic and is not a covered benefit. Coverage is at risk when the record indicates cosmetic intent or does not substantiate the functional medical-necessity requirements.

Document the functional purpose of the procedure and the underlying trauma, disease, congenital defect, or qualifying cleft-related deformity.
Support significant symptoms, persistent obstruction despite conservative management, required photographs, and the coordinated surgical rationale.
Do not rely on insufficient or incomplete documentation to establish medical necessity.

Denial Risk

Septoplasty Criteria Not Met

Septoplasty may be denied when the applicable clinical criteria are not met or when required treatment failure and supporting documentation are absent.

No documented failure of 4 to 6 weeks of appropriate medical therapy for continuous obstruction.
Recurrent sinusitis is not documented as related to the deviated septum or was not treated with appropriate medical and antibiotic therapy.
The record does not establish recurrent epistaxis related to septal deformity, necessary intranasal access, or association with cleft palate repair.
Required clinical findings and supporting records are incomplete.

Denial Risk

Incomplete Functional Rhinoplasty Documentation

Functional rhinoplasty is at risk for denial when required documentation is incomplete, including symptom findings, photographs, conservative-treatment duration, or supporting clinical records.

Missing documentation of significant obstruction or symptom duration and severity
Missing standard four-way preoperative photographs when an external deformity is present
Less than three months of documented conservative management or no results of treatment
Missing evidence that septoplasty and turbinectomy alone are insufficient
Missing documentation of gross obstruction on the same side as the septal deviation or of a coordinated medically necessary septoplasty procedure

Unsupported block type: billing_rule

Denial Risk

Unproven Nasal Valve Procedures

Certain nasal valve procedures and devices are considered experimental, investigational, and/or unproven under the policy. Low-energy, temperature-controlled radiofrequency remodeling is not medically necessary because it is not superior to or more beneficial than standard treatments.

Repair of nasal valve collapse or vestibular lateral wall stenosis with absorbable nasal implant(s), such as Latera®
Repair of nasal valve collapse with low-energy, temperature-controlled radiofrequency subcutaneous or submucosal remodeling, such as VivAer®
The policy identifies these procedures/devices as experimental, investigational, and/or unproven; verify applicable benefit and plan-specific coverage rules before billing.

Treatment areaCan remodel nasal cartilage and soft tissue throughout the nasal valve, including the septum, inferior turbinate, and nasal valve itself