CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Septoplasty/Rhinoplasty

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

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

This policy governs coverage, medical-necessity review, prior authorization, and exclusions for nasal surgery, including septoplasty, rhinoplasty, septal dermatoplasty, rhinophyma procedures, and surgical repair of vestibular stenosis. Requirements vary by commercial, BadgerCare Plus/Medicaid SSI, Medicare Advantage, Family Health Center, and third-party administration products.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicySeptoplasty/Rhinoplasty

Policy CodePolicy N/A

Change TypeRevision

Effective DateMay 1, 2026

Next Review DateJanuary 26, 2024

Key ActionSubmit applicable requests for prior authorization through the Health Plan provider portal.

SourceLink

POLICY UPDATE CHANGES

Autologous fat grafting for septoplasty was removed from the experimental/investigational exclusion section.

The policy states that Clarifix for chronic rhinitis treated with cryotherapy remains experimental/investigational.

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy.

RequiredPrior authorization for applicable procedures and products

2Commercial procedure groups with explicit criteria

3Experimental/investigational nasal procedures

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.

CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Septoplasty/Rhinoplasty

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

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

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicySeptoplasty/Rhinoplasty

Policy CodePolicy N/A

Change TypeRevision

Effective DateMay 1, 2026

Next Review DateJanuary 26, 2024

Key ActionSubmit applicable requests for prior authorization through the Health Plan provider portal.

SourceLink

POLICY UPDATE CHANGES

Autologous fat grafting for septoplasty was removed from the experimental/investigational exclusion section.

The policy states that Clarifix for chronic rhinitis treated with cryotherapy remains experimental/investigational.

Align, Align DSNP, and Great Plains Medicare Advantage plans were added to the policy.

RequiredPrior authorization for applicable procedures and products

2Commercial procedure groups with explicit criteria

3Experimental/investigational nasal procedures

InterQualMedical-necessity review criteria

5Product or program sections addressed

Coverage Criteria

Septal dermatoplasty

Septal dermatoplasty is considered reconstructive and medically necessary when ALL of the following are met.

Septal dermatoplasty criteria

Documented impairment: There is documented functional impairment due to diseased nasal mucosa.
Examples include obstruction, pain, or bleeding.
Expected benefit from graft: The functional impairment will be eliminated by a skin graft.

Rhinophyma

Rhinophyma is considered reconstructive and medically necessary when ALL of the following are met.

Rhinophyma criteria

ONE qualifying clinical indication
- There is prolonged, persistent obstructed nasal breathing due to rhinophyma.
- There is chronic infection or bleeding due to rhinophyma that is unresponsive to medical management.
Anatomic documentation: Photos clearly document rhinophyma as the primary cause of an anatomic mechanical nasal airway obstruction or chronic infection and are consistent with the clinical examination.
Procedure purpose: The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity, or is designed to address the chronic infection.

External medical-necessity criteria

For procedures reviewed under the applicable product program, medical necessity is determined using the referenced external criteria.

InterQual or program-specific review: The procedure must satisfy applicable InterQual criteria or, for BadgerCare Plus/Medicaid SSI and Medicare Advantage, applicable ForwardHealth or Medicare guidelines.

The policy does not reproduce the InterQual, ForwardHealth, or Medicare clinical criteria.

For commercial coverage, services that do not meet the applicable clinical criteria are denied as not medically necessary. Services not listed with clinical criteria are considered experimental/investigational.

Rhinaer is considered experimental/investigational based on the applicable technology assessment.

Vivaer radiofrequency ablation of nasal valve collapse is considered experimental/investigational based on the applicable technology assessment.

Clarifix cryotherapy for treatment of chronic rhinitis is considered experimental/investigational based on the applicable technology assessment.

The Family Health Center does not cover surgical services performed in inpatient, outpatient surgery, observation, or ambulatory surgical settings.

A commercial service that does not meet the applicable clinical criteria is considered not medically necessary and will be denied.

Authorization and Documentation Requirements

Prior Authorization

Submit commercial prior authorization

Commercial requests require prior authorization through the Health Plan provider portal. The Health Plan uses InterQual criteria to determine medical necessity.

Prior Authorization

Submit Medicaid prior authorization

BadgerCare Plus/Medicaid SSI requests require prior authorization through the Health Plan provider portal. Review applicable ForwardHealth requirements for the procedure and confirm that clinical criteria are met.

Prior Authorization

Obtain Medicare Advantage authorization

Medicare Advantage requests require prior authorization through the Health Plan provider portal. The Health Plan follows Medicare guidelines when criteria are met.

Nasal Surgery Overview

Nasal surgery may involve the external or internal nose, septum, or turbinates. Procedures may rearrange or excise supporting bone, cartilage, or overlying nasal tissue, including skin.

Procedure Definitions

Nasal surgery

ScopeAny procedure performed on the external or internal structures of the nose, septum, or turbinate.

Typical surgical changesGenerally involves rearrangement or excision of supporting bony and cartilaginous structures.

Overlying tissueMay involve incision or excision of the overlying skin of the nose.

Rhinoplasty

DefinitionSurgery performed to reshape the nose.

Usual purposeGenerally performed for cosmetic reasons.

Traumatic-injury exception

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicySeptoplasty/Rhinoplasty

Policy CodePolicy N/A

Change TypeRevision

Effective DateMay 1, 2026

Next Review DateJanuary 26, 2024

Key ActionSubmit applicable requests for prior authorization through the Health Plan provider portal.

SourceLink

On This Page

Prior Authorization

Review TPA coverage requirements

TPA requests require prior authorization through the Health Plan provider portal, with medical necessity reviewed using InterQual criteria. Review the member’s Summary Plan Description for coverage, limitations, and exclusions; if it does not contain specific guidelines or criteria, commercial criteria apply.

Documentation Required

Submit rhinophyma photographs

For rhinophyma procedures, submit photographs that clearly document rhinophyma as the primary cause of an anatomic mechanical nasal airway obstruction or chronic infection and that are consistent with the clinical examination.

Documentation Required

Document septal dermatoplasty necessity

For septal dermatoplasty, document functional impairment due to diseased nasal mucosa and explain how a skin graft will eliminate the impairment. Functional impairment may include obstruction, pain, or bleeding.

Billing Rule

Verify ForwardHealth requirements

For BadgerCare Plus/Medicaid SSI, verify payable services, provider types, specialties, and places of service in the ForwardHealth interactive fee schedule. Also review the Physician’s Handbook requirements for restorative plastic surgery and procedures.

Denial Risk

Meet the listed clinical criteria

Commercial services that do not meet the stated clinical criteria will be denied as not medically necessary. Services not listed with clinical criteria are considered experimental/investigational.

Denial Risk

Avoid experimental nasal procedures

Rhinaer, Vivaer radiofrequency ablation of nasal valve collapse, and Clarifix cryotherapy for chronic rhinitis are considered experimental/investigational.

Denial Risk

Confirm Family Health Center site of service

Family Health Center does not cover surgical services performed in inpatient, outpatient surgery, observation, or ambulatory surgical settings. Confirm that the planned site of service is eligible before scheduling the procedure.

A functional indication may apply when a recent traumatic injury to the nose results in nasal airway obstruction.

Septoplasty

DefinitionSurgery to repair the nasal septum, the tissue, bone, and cartilage that separates the nostrils.

Structural objectiveStraightens and centers the septum.

Breathing objectiveImproves nasal breathing and reduces nasal obstruction.

Surgical repair of vestibular stenosis

DefinitionSurgery to repair collapsed internal nasal valves.

Repair techniqueUses placement of a spreader graft or batten graft.

Treatment objectiveTreats nasal airway obstruction.