CurrentProvidence Health PlanPolicy 247

Rhinoplasty and Other Nasal Surgeries

Customize your policy alerts

Sign up for Providence Health Plan Policy 247 alerts

Get alerted when Policy 247 changes without checking for updates manually.

Monitor payer policy activity

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

This Medicare medical policy governs coverage and medical-necessity review for rhinoplasty, nasal valve procedures, nasal radiofrequency ablation, and nasal cryoablation for Providence Medicare Advantage plan administration. CMS guidance governs when it conflicts with Company policy.

Policy Summary

PayerProvidence Health Plan

PolicyRhinoplasty and Other Nasal Surgeries

Policy CodePolicy 247

Change TypeAnnual reviewno material changes

Effective DateNovember 1, 2026

Last ReviewOct 1, 2026

Next Review DateOctober 1, 2027

Key ActionObtain prior authorization before submitting an unlisted code for a potentially covered service to help avoid post-service denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentProvidence Health PlanPolicy 247

Rhinoplasty and Other Nasal Surgeries

Customize your policy alerts

Sign up for Providence Health Plan Policy 247 alerts

Get alerted when Policy 247 changes without checking for updates manually.

Monitor payer policy activity

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

Policy Summary

PayerProvidence Health Plan

PolicyRhinoplasty and Other Nasal Surgeries

Policy CodePolicy 247

Change TypeAnnual reviewno material changes

Effective DateNovember 1, 2026

Last ReviewOct 1, 2026

Next Review DateOctober 1, 2027

Key ActionObtain prior authorization before submitting an unlisted code for a potentially covered service to help avoid post-service denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9CPT codes for rhinoplasty and cleft-related rhinoplasty

4CPT codes for nasal implants and ablation procedures

0Policy cross references

Not establishedMedicare criteria for certain nasal procedures

No changesRevision status

Coverage Criteria

General Rhinoplasty Procedures

Coverage is determined under applicable Medicare Guidelines.

Medicare guideline review: Coverage is determined under applicable Medicare Guidelines for general rhinoplasty procedures reported with CPT 30400, 30410, 30420, 30430, 30435, or 30450.

The policy does not reproduce additional clinical criteria for these procedures.

Cleft-Related Reconstructive Rhinoplasty

Coverage is governed by Local Coverage Determination (LCD) L35163.

Congenital cleft-related nasal deformity: Rhinoplasty for nasal deformities secondary to congenital cleft lip and/or palate, reported with CPT 30460 or 30462, may be considered reconstructive according to LCD L35163.

Apply the full criteria in LCD L35163; the policy does not reproduce those criteria.

Absorbable Nasal Implants and Nasal Ablation Procedures

Apply Company medical-policy criteria when applicable Medicare coverage criteria are not fully established for the plan service area.

No established Medicare coverage criteria: Company medical-policy criteria are applied for medical-necessity decision-making for absorbable nasal implants, nasal radiofrequency ablation, and nasal cryoablation because applicable Medicare statutes, regulations, NCDs, LCDs, or other regulatory guidance do not fully establish coverage criteria for these services in the plan service area.

The policy identifies this coverage framework but does not provide additional procedure-specific Company criteria in the provided text.

Applicable Procedure Codes

General Rhinoplasty ProceduresCPT

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)

Rhinoplasty Secondary to Congenital Cleft Lip and/or PalateCPTCovered

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

Absorbable Nasal Implants, Nasal Radiofrequency Procedures, and Nasal CryoablationCPT

30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)
30469	Repair of nasal valve collapse with low energy, temperature-controlled (ie, radiofrequency) subcutaneous/submucosal remodeling
31242	Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve
31243	Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization for Unlisted Potentially Covered Services

For an unlisted code representing a potentially covered service addressed in this policy, obtain prior authorization before furnishing the service to help avoid a post-service denial.

Prior authorization is recommended before submitting an unlisted code for a potentially covered service.

Documentation Required

Submit Medical-Necessity Documentation

Submit clinical documentation supporting medical necessity. Medical-necessity determinations consider applicable coverage and benefit criteria, current standards of care, the member’s medical history and clinical circumstances, physician recommendations, clinical notes, and plan medical-director involvement when appropriate.

Include relevant diagnoses, conditions, functional status, co-morbidities, physician recommendations, and clinical notes.

Policy Scope and Subject

This policy addresses primary and secondary rhinoplasty, rhinoplasty for nasal deformity related to congenital cleft lip and/or palate, nasal valve repair using absorbable implants or radiofrequency remodeling, and posterior nasal nerve ablation using radiofrequency or cryoablation. General rhinoplasty services are reviewed under applicable Medicare Guidelines, while cleft-related rhinoplasty may be considered reconstructive under LCD L35163. Because fully established Medicare coverage criteria are not available for absorbable nasal implants, nasal radiofrequency ablation, or nasal cryoablation in the plan service area, Company medical-policy criteria are applied for medical-necessity determinations.

Policy Summary

PayerProvidence Health Plan

PolicyRhinoplasty and Other Nasal Surgeries

Policy CodePolicy 247

Change TypeAnnual reviewno material changes

Effective DateNovember 1, 2026

Last ReviewOct 1, 2026

Next Review DateOctober 1, 2027

Key ActionObtain prior authorization before submitting an unlisted code for a potentially covered service to help avoid post-service denial.

SourceLink

On This Page

Support requests with current, widely used treatment guidelines or appropriate peer-reviewed clinical evidence when Medicare coverage criteria are not fully established.

Billing Rule

Support Unlisted-Code Claims Before Service

Support unlisted-code claims before service with authorization and sufficient clinical information for medical-necessity, coding, and pricing review. All unlisted codes are reviewed at the claim level, and authorization does not guarantee coverage or payment.

Obtain prior authorization for unlisted codes describing potentially covered services.
Provide records that substantiate the service, diagnosis, medical necessity, and correct coding.

Denial Risk

Unlisted Code for Non-Covered Service

An unlisted code submitted for a non-covered service addressed in this policy will be denied as not covered.

Code issuance, a Medicare fee-schedule amount, or inclusion in a code list does not establish that a service is covered or medically reasonable and necessary.

Denial Risk

Establish Medicare Medical Necessity

Medicare coverage is limited to services or items that are medically reasonable and necessary to treat illness or injury. If the provider does not establish the applicable Medicare benefit, coverage, and individualized medical-necessity requirements, the service may be denied.

Address the member’s benefit and applicable Medicare coverage criteria, including relevant statutes, regulations, NCDs, LCDs, and other governing guidance.
Document how the service meets current standards of care and the member’s diagnoses, conditions, functional status, co-morbidities, medical history, physician recommendations, and clinical findings.
When coverage criteria are not fully established, support medical necessity with current, widely used treatment guidelines or appropriate peer-reviewed clinical evidence.

Note

Follow CMS Precedence and Company-Criteria Fallback

CMS guidance governs if it conflicts with Company Medicare policy. When applicable Medicare statutes, regulations, NCDs, LCDs, or other regulatory guidance do not fully establish coverage criteria for the plan’s service area, Company criteria may be applied for medical-necessity decisions.

Use the most current applicable CMS reference available for the service.
If no applicable Medicare coverage criteria are established for the plan’s service area, apply the Company criteria and submit documentation addressing those criteria.