ModifiedUnitedHealthcarePolicy MMP060.15

Ear, Nose, and Throat Procedures

Medicare-focused coverage guidance for a range of ENT surgical procedures (sinus surgeries, rhinoplasty, septoplasty, vestibular stenosis repair, intranasal repair, radiofrequency nasal valve treatment, rhinophyma excision) referencing UnitedHealthcare commercial policies and applicable LCDs/LCAs where noted. Affects Medicare beneficiaries and providers performing these procedures.

Policy Summary

PayerUnitedHealthcare

PolicyEar, Nose, and Throat Procedures

Policy CodePolicy MMP060.15

Change TypeRemoved procedure references and CPT codesupdated CMS links

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionDocument photographic and clinical exam evidence and ensure a ≥4-week trial of conservative management (including nasal steroids when appropriate) before prior authorization for reconstructive rhinoplasty procedures.

SourceLink

POLICY UPDATE CHANGES

Removed content/language addressing posterior nasal nerve ablation using radiofrequency or cryoablation (e.g., Clarifix) and Rhinophototherapy.

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled: Cosmetic and Reconstructive Procedures and Omnibus Codes.

Removed CPT codes 31242, 31243, and 30999 from Applicable Codes.

Updated list of CMS documents in the Medicare Coverage Database to reflect current information.

Archived previous policy version MMP060.14.

Aug 13, 2025Policy approval date

2024Rhinoplasty meta-analysis patients

11.3%Revision rate (example cohort)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

43Articles in Spielmann review

Coverage Criteria for Rhinoplasty and Other Nasal Procedures

Rhinoplasty – Medically Necessary Criteria

Rhinoplasty is considered reasonable and necessary when ALL of the following are met:

Photographic documentation (frontal, lateral, and worm's‑eye views) of the individual's condition is provided.

Required when procedure is performed for correction or repair (see supporting documentation requirements)

Indication for reconstructive/functional rhinoplasty: Procedure is performed for correction or repair of one or more of the following: (1) secondary to trauma, disease, or congenital defect with nasal airway obstruction that has not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone; (2) nasal deformity secondary to cleft lip/palate or other congenital craniofacial deformity causing functional impairment; (3) chronic, non‑septal nasal obstruction due to vestibular stenosis (collapsed internal valves).

Criteria align with AAO‑HNS and ASPS statements

Rhinoplasty tip (reconstructive) exception: When proposing tip rhinoplasty as reconstructive (rather than cosmetic), ALL of the following must be present: (a) prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction; (b) photographs clearly document tip drop as the primary cause of obstruction and are consistent with the clinical exam; (c) the proposed procedure is designed to correct the anatomic mechanical obstruction by lifting the nasal tip and relieve the airway obstruction; (d) nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing); and (e) obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.>= 4 weeks conservative management

Conservative management requirement before considering tip rhinoplasty as reconstructive

Clinical prerequisites and documentation

Supporting clinical criteria and preparatory requirements referenced in the evidence and consensus statements

Conservative therapy before surgery: Patient should have a trial of appropriate medical therapy prior to septoplasty or related reconstructive rhinoplasty when clinically indicated (example: a 4‑week nasal steroid trial for septoplasty candidates).4 weeks

From clinical consensus statements (Han et al. 2015)

Objective/Clinical evaluation: Anterior rhinoscopy or nasal endoscopy is adequate to determine septal deviation; acoustic rhinometry/rhinomanometry are not required to establish septal deviation but may be helpful when nasal obstruction is the primary presenting issue.

Consensus: anterior rhinoscopy/nasal endoscopy adequate for diagnosis

Documentation for procedures and coding: Documented clinical findings (exam and photos where required), and applicable procedure/diagnosis codes (e.g., CPT 30120 for rhinophyma, septoplasty and rhinoplasty CPTs, and relevant ICD‑10 codes for nasal deformity or fracture) should be provided per payer prior authorization and claims requirements.

Covered Indications (functional/reconstructive rhinoplasty)

Covered when surgery is intended to address functional nasal airway impairment or to reconstruct deformities affecting function:

Functional/Reconstructive Indications

Adjunctive procedures on the nasal septum, nasal valve, turbinates, or paranasal sinuses may be included when they impact nasal shape or airway function.
If adjunctive procedures do not impact nasal shape or appearance they may be excluded from the guideline definition of rhinoplasty (AAO‑HNS)

Nasal Valve Compromise (NVC): Surgical treatment of nasal valve compromise is an accepted primary mode of treatment; diagnosis is primarily clinical (history and physical exam) because there is no gold‑standard objective test. Surgical approaches targeted to support the lateral nasal wall/alar rim are distinct from septoplasty/turbinate procedures and may be necessary to address NVC.

Evidence largely from uncontrolled studies; well‑designed trials lacking (Spielmann et al. 2009)

Rhinoplasty and other nasal surgery performed solely to improve appearance are considered cosmetic and are not covered. The policy excludes procedures done only for aesthetic reasons in the absence of signs or symptoms of functional abnormality; coverage is limited to procedures intended to correct or reconstruct anatomic defects that impair nasal airway function or arise from trauma, disease, or congenital deformity.

Cosmetic surgery and related expenses are not covered except in narrow situations: when the procedure is required for the prompt repair of an accidental injury or to improve the functioning of a malformed body member. Examples include repair after severe burns or facial trauma where reconstruction is medically necessary; routine cosmetic reshaping without functional benefit remains excluded.

Adjunctive nasal procedures that do not change the nasal shape or appearance may fall outside the guideline definition of rhinoplasty. When an intervention does not impact external nasal form, it may be excluded from rhinoplasty considerations and treated according to the relevant procedure-specific coverage guidance.

Rhinoplasty performed as the primary treatment for an obstructive sleep disorder is not considered reasonable and necessary and is therefore excluded from coverage under this policy.

Where the published literature consists primarily of low‑level studies or technique descriptions rather than well‑designed comparative trials, the long‑term patient benefit is uncertain. The policy recognizes that many available reports are uncontrolled and that stronger evidence from randomized, prospective trials is generally lacking to support broad coverage conclusions.

Specifically for nasal valve surgery, many described techniques lack evidence from randomized controlled trials. Systematic reviews have found the literature is dominated by level IV case series and small nonrandomized studies, leaving uncertainty about comparative effectiveness and long‑term outcomes.

Applicable Procedure and Diagnosis Codes

Balloon Sinus Ostial Dilation CPT CodesCPT

31295	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, transnasal or via canine fossa
31296	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium
31297	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); sphenoid sinus ostium
31298	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia
31299	Unlisted procedure, accessory sinuses

Functional Endoscopic Sinus Surgery (FESS) CPT CodesCPT

31240	Nasal/sinus endoscopy, surgical; with concha bullosa resection
31253	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)
31257	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
31287	Nasal/sinus endoscopy, surgical, with sphenoidotomy
31288	Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

Intranasal Repair CPT Codes (may be cosmetic)CPT

30540	Repair choanal atresia; intranasal
30545	Repair choanal atresia; transpalatine
30620	Septal or other intranasal dermatoplasty (does not include obtaining graft)

Radiofrequency nasal valve treatment CPT CodeCPT

30469

Repair of nasal valve collapse with low energy, temperature-controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling

Rhinophyma Excision CPT CodeCPT

30120

Excision or surgical planing of skin of nose for rhinophyma

Rhinoplasty CPT CodesCPT

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
30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)

Septoplasty CPT CodeCPT

30520

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

Vestibular Stenosis Repair CPT CodeCPT

30465

Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)

ICD-10 Diagnosis Codes (selected)ICD-10

C30.0	Malignant neoplasm of nasal cavity
J32.0	Chronic maxillary sinusitis
J32.1	Chronic frontal sinusitis
J32.2	Chronic ethmoidal sinusitis
J32.3	Chronic sphenoidal sinusitis
J32.4	Chronic pansinusitis
J34.2	Deviated nasal septum
J34.8202	Internal nasal valve collapse, dynamic
J34.8211	External nasal valve collapse, static
J34.8212	External nasal valve collapse, dynamic

1–10 of 11

1/2

Applicable Codesmixed

S02.2XXA	Fracture of nasal bones, initial encounter for closed fracture.
S02.2XXB	Fracture of nasal bones, initial encounter for open fracture.
S02.2XXD	Fracture of nasal bones, subsequent encounter for fracture with routine healing.
S02.2XXG	Fracture of nasal bones, subsequent encounter for fracture with delayed healing.
S02.2XXK	Fracture of nasal bones, subsequent encounter for fracture with nonunion.
S02.2XXS	Fracture of nasal bones, sequela.
30120	Surgery for Rhinophyma
L71.1	Rhinophyma

Removed Applicable CPT CodesCPT

31242	CPT code removed from Applicable Codes
31243	CPT code removed from Applicable Codes
30999	CPT code removed from Applicable Codes

Conservative management duration

Conservative management duration>= 4 weeks (including nasal steroids or immunotherapy where appropriate)

ContextRequired prior to considering rhinoplasty tip procedures described as reconstructive

Documentation linkReferenced in rhinoplasty criteria defining tip rhinoplasty exception

Spielmann systematic review study size threshold

Provider Requirements, Documentation, and Authorization

Prior Authorization

Refer to LCDs/InterQual for Authorization

Refer to Medicare LCDs/LCAs and InterQual where applicable; compliance with specific LCD/LCA criteria is required for states/territories that have them. When no applicable LCD/LCA exists for a state/territory, refer to InterQual CP: Procedures, Septoplasty or the UnitedHealthcare Commercial Medical Policy titled Rhinoplasty and Other Nasal Procedures as indicated.

Follow specific LCD/LCA criteria for septoplasty and vestibular stenosis repair where published
Use InterQual criteria for septoplasty in states without LCDs/LCAs
See UnitedHealthcare Commercial policy for rhinoplasty guidance when LCDs/LCA do not apply

Billing Rule

Applicable Billing and Coding

Background and Evidence Summary

Background: This policy provides Medicare‑focused coverage guidance for a range of ENT surgical procedures, including rhinoplasty and associated interventions (e.g., septoplasty, vestibular stenosis repair, intranasal repair, radiofrequency nasal valve treatment, rhinophyma excision), as well as sinus procedures such as balloon sinus ostial dilation and functional endoscopic sinus surgery. It references professional society guidance and relevant CMS documents, and directs providers to applicable LCDs/LCAs or InterQual criteria where those local coverage policies exist.

Definitions and Terminology

Cosmetic Surgery

DefinitionSurgery performed to reshape normal structures of the body to improve the patient's appearance and self-esteem

Coverage stanceCosmetic surgery and related expenses are not covered except when required for prompt repair of accidental injury or to improve function of a malformed body member

ReferenceSee Medicare Benefit Policy Manual, Chapter 16, §120 and multiple LCDs for Cosmetic and Reconstructive Surgery

Reconstructive Surgery

DefinitionSurgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, tumors, or disease

PurposeGenerally performed to improve function and may also approximate normal appearance

Policy Summary

PayerUnitedHealthcare

PolicyEar, Nose, and Throat Procedures

Policy CodePolicy MMP060.15

Change TypeRemoved procedure references and CPT codesupdated CMS links

Effective DateSeptember 1, 2025

Next Review DateN/A

SourceLink

On This Page

Providers should retain documentation and follow payer/LCD/InterQual requirements

>= 10 patients per study

Study inclusion periodSpielmann et al. review included articles from 1970–2008

Follow-up requirementMinimum of one month follow-up for every patient in included studies

Certain CPT and ICD-10 codes are commonly applicable for septoplasty, rhinoplasty, vestibular stenosis repair, and related procedures. Providers must submit accurate, complete codes and adhere to CPT/CMS coding guidance when billing.

Include appropriate CPT procedure codes and relevant ICD-10 diagnosis codes on claims
Follow CMS and CPT coding guidance; references to CPT/CMS are definitional and do not guarantee payment

Prior Authorization

Delegate-Managed Prior Authorization

For Medicare Advantage members, if a delegated vendor manages utilization management or prior authorization, providers must follow the delegate's prior authorization and UM requirements in addition to UnitedHealthcare policy.

When delegate-managed, use the delegate's UM/prior authorization process and requirements
Confirm delegate jurisdiction before submitting authorization requests

Documentation Required

Conservative Management Requirement for Rhinoplasty Tip

Rhinoplasty tip procedures are generally cosmetic but may be considered reconstructive and medically necessary only when photographic and clinical documentation show tip drop as the primary anatomic cause of nasal airway obstruction and symptoms persist despite conservative therapy.

Require photographic documentation (frontal, lateral, and worm's eye views) when rhinoplasty is performed for correction/repair
Conservative management (including nasal steroids or immunotherapy where appropriate) must have been tried for ≥ 4 weeks prior to considering rhinoplasty tip procedures

Documentation Required

Conservative Therapy Prior to Septoplasty

A trial of conservative therapy is expected prior to septoplasty in many coverage determinations. A minimum 4-week nasal steroid trial is identified as adequate conservative treatment in relevant guidance when clinically appropriate.

Document at least a 4-week trial of nasal steroids prior to septoplasty when nasal obstruction symptoms are present
If inferior turbinate hypertrophy is present, document prior conservative measures and rationale for combining procedures

Documentation Required

Rhinoplasty Photographic Documentation

When rhinoplasty is performed for correction or repair, photographic documentation should include frontal, lateral, and worm's eye views to correlate with the clinical exam.

Retain and be able to produce preoperative photos showing frontal, lateral, and worm's eye views if rhinoplasty is billed as reconstructive/functional

Documentation Required

Clinical Exam Documentation for Septoplasty

Clinical documentation of septal deviation may be established by anterior rhinoscopy or nasal endoscopy; routine preoperative photos are not required for septoplasty under the consensus statement, though payers commonly request additional testing.

Document septal deviation by anterior rhinoscopy and/or nasal endoscopy in the medical record
Recognize that payers may still request acoustic rhinometry, rhinomanometry, photos, or imaging despite consensus guidance

Denial Risk

Cosmetic Surgery Exclusion — Denial Risk

Cosmetic surgery and related expenses are excluded except when required for prompt repair after accidental injury or to improve function of a malformed body member. Procedures performed solely for appearance without functional abnormality may be denied.

Do not bill medically unless documentation shows functional impairment or meets reconstructive criteria
If surgery is for repair after accidental injury, document timing and medical necessity for prompt repair

Documentation Required

Prior Testing Frequently Required by Payers

Payers frequently require prior tests and documentation (e.g., acoustic rhinometry/rhinomanometry, nasal endoscopy, photographs, imaging) prior to payment approval for septoplasty and related procedures; include these results in the record when performed.

Include results of nasal endoscopy and any physiologic testing performed (acoustic rhinometry/rhinomanometry) when available
Provide imaging and preoperative photographs if requested by payers

Documentation Required

Provider Documentation and Claims Submission

Providers must retain and have access to documentation to support coverage determinations and claims. Failure to retain or produce requested documentation or to submit accurate claims may affect coverage and payment.

Maintain complete medical records, operative notes, photos, and conservative therapy documentation for audit or review
Ensure claims accurately reflect services provided and follow CPT/CMS billing guidance

ReferenceRefer to multiple LCDs for Cosmetic and Reconstructive Surgery

Cosmetic Surgery (duplicate)

Definition (duplicate)Surgery performed to reshape normal structures of the body to improve the patient's appearance and self-esteem

Coverage note (duplicate)Cosmetic surgery is not covered except when required for prompt repair of accidental injury or to improve functioning of a malformed body member

GuidanceExclusion examples include non-therapeutic aesthetic procedures; therapeutic procedures coincidentally cosmetic may be covered

Reconstructive Surgery (duplicate)

Definition (duplicate)Surgery on abnormal structures caused by congenital defects, developmental abnormalities, trauma, tumors, or disease

Coverage note (duplicate)Reconstructive surgery is generally performed to improve function and may approximate normal appearance

ReferenceSee Medicare LCDs for further details

Rhinoplasty

DefinitionRhinoplasty is a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway

Functional vs cosmeticChange in appearance may result from addressing a functional abnormality (e.g., deviated septum, nasal valve compromise) or may be primarily aesthetic

Adjunctive proceduresMay include procedures on septum, nasal valve, turbinates, or paranasal sinuses; if performed without impact on nasal shape they may be excluded from rhinoplasty definition

Nasal Valve Compromise (NVC)

DefinitionNasal Valve Compromise (NVC) is defined by anatomic and functional features best diagnosed with history and physical exam

Objective testingThere is no gold-standard objective test for NVC; radiographic tests (CT/MRI) are used mainly to rule out other disease

Role of surgerySurgical treatment is a primary mode of treatment though most evidence comes from uncontrolled studies