CurrentUnitedHealthcarePolicy CS107IN.09

Rhinoplasty and Other Nasal Procedures (for Indiana Only)

State-specific medical policy for rhinoplasty and other nasal procedures applicable only to Indiana members; defines medical necessity criteria for nasal valve procedures/repair of nasal vestibular stenosis or alar collapse, rhinophyma excision, references InterQual for nasal polypectomy, lists unproven procedures, applicable CPT/HCPCS codes, documentation requirements, definitions, and supporting evidence summaries.

Policy Summary

PayerUnitedHealthcare

PolicyRhinoplasty and Other Nasal Procedures (for Indiana Only)

Policy CodePolicy CS107IN.09

Change TypeClarifications and documentation requirementsevidence/reference updates

Effective DateMay 1, 2026

Next Review Date

Key ActionEnsure the patient medical record includes relevant history, exam, diagnostic results, photos, modified Cottle maneuver findings, baseline symptom scores, and a clear surgical plan (including graft need) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Added language that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Added list of what documentation includes (medical history, physical exam, and diagnostic test results).

Updated definition of 'External Nasal Valve'.

Updated Clinical Evidence and References sections to reflect current information.

Archived previous policy version CS107IN.08.

3Procedures with explicit coverage criteria (nasal valve, rhinophyma, polypectomy reference)

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Coverage Summary

This policy is state-specific and applies only to Indiana with an effective date of May 1, 2026 (Policy CS107IN.09). The scope covers rhinoplasty and other nasal procedures for Indiana members and defines medical necessity criteria for selected reconstructive nasal procedures.

The coverage stance is mixed: the policy includes explicit, detailed reconstructive coverage criteria for certain procedures (nasal valve repair/repair of nasal vestibular stenosis or alar collapse and rhinophyma excision), references an external source (InterQual) for nasal polypectomyunproven / not medically necessary due to insufficient evidence.

Procedures with explicit criteria in this policy include: nasal valve procedures/repair of nasal vestibular stenosis or alar collapse (with detailed multi-item criteria such as prolonged persistent obstruction, prior treatment of other causes, documentation of dynamic collapse, modified Cottle maneuver improvement, photographs, and a clear surgical plan), and rhinophyma excision (with criteria tied to obstruction or chronic infection/bleeding and photographic documentation). Nasal polypectomy is addressed by directing reviewers to InterQual for medical necessity criteria.

Procedures listed as unproven / not medically necessary include: absorbable polylactic acid nasal cartilage support implants (e.g., Latera), nasal septal swell body reduction for nasal obstruction, posterior nasal nerve or sphenopalatine ganglion ablation by any method (e.g., RhinAer, ClariFix) for chronic rhinitis, and radiofrequency treatment of nasal valves (e.g., VivAer ARC Stylus).

The policy clarifies that benefit coverage is determined by applicable federal, state, or contractual requirements and that documentation requirements have been strengthened: medical records documentation must fully support medical necessity but does not guarantee coverage.

Key thresholds and trial-entry examples

Prolonged, Persistent Nasal Airway Obstruction (definition)Has not responded to 6 weeks of medical management such as nasal steroids, antihistamines, and decongestants

NOSE baseline examples (implant/TCRF studies)Study baselines reported in severe/extreme range; examples: San Nicoló mean 76.7 (range 55–100), Silvers/RCT baseline ~76–78, Yao/TCRF cohorts baseline >=60 or means ~80

rTNSS baseline commonly required>= 6 (used as enrollment threshold in multiple PNN/rhinitis trials)

rTNSS subscore eligibility (examples)Trials required minimum subscores: rhinorrhea 2–3; congestion 1–3; itching/sneezing 0–3 (Ehmer et al., Takashima criteria)

Responder definition (PNN/cryo/TCRF studies)>= 30% reduction in TNSS/rTNSS from baseline (commonly used); NOSE responder definitions: >=20-point reduction or at least one severity class improvement

Silvers/VivAer RCT primary responder threshold>=20% NOSE reduction or one severity class improvement (Silvers RCT primary endpoint)

Medical-Necessity Criteria

Unproven / Not Medically Necessary

Coding

Applicable CPT codes (reference only; codes with * are not managed for medical necessity review for Indiana at policy effective date)CPT

30117	Excision or destruction (e.g., laser) of intranasal lesion; internal approach.
30120	Excision or surgical planing of skin of nose for rhinophyma.
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.

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Applicable HCPCS codesHCPCS

L8699

Prosthetic implant, not otherwise specified

FDA device clearances / informational codesmixed

VivAer Stylus 510(k) K200300	VivAer Stylus cleared March 2020 for coagulation of soft tissue in nasal airway to treat nasal airway obstruction by shrinking submucosal tissue in internal nasal valve area.
ClariFix 510(k) K190356	ClariFix cryosurgical device cleared February 14, 2017 for destruction of unwanted tissue including in adults with chronic rhinitis.
RhinAer Stylus 510(k) K221907	RhinAer Stylus cleared July 29, 2022 indicated for destruction of soft tissue in nasal airway including posterior nasal nerve regions for chronic rhinitis.
Latera Absorbable Nasal Implant 510(k) K161191	Latera implant cleared June 23, 2016 to support nasal upper and lower lateral cartilage (absorbable polylactic acid implant).

Codes mentioned in body/references (no explicit code lists in this part)mixed

No codes listed

Provider Actions & Prior Authorization

Unsupported block type: prior_auth

Unsupported block type: documentation

Unsupported block type: prior_auth

Unsupported block type: denial_risk

Unsupported block type: billing_rule

Background & Evidence Summaries

Background: This is a state-specific policy applicable to Indiana only. For state-specific rhinoplasty medical necessity criteria, the policy directs readers to the Indiana Health Coverage Programs Provider Reference Module: Surgical Services.

The policy describes reconstructive indications and clinical coverage criteria for nasal valve repair (nasal valve procedures/repair of nasal vestibular stenosis or alar collapse) and rhinophyma excision, and it refers users to InterQual CP: Procedures, Polypectomy, Nasal for detailed criteria regarding nasal polypectomy.

The document notes certain procedures are considered unproven / not medically necessary because of insufficient evidence of safety and/or efficacy, specifically naming absorbable polylactic acid nasal cartilage support implants (e.g., Latera), septal swell body reduction, posterior nasal nerve or sphenopalatine ganglion ablation (any method, e.g., RhinAer, ClariFix), and radiofrequency treatment of nasal valves (e.g., VivAer ARC Stylus).

Administrative and coding context: the policy lists applicable CPT and HCPCS codes for reference and states that benefit coverage is governed by federal, state, or contractual requirements. It also notes that nasal surgical claims may be subject to coding review and refers to Indiana prior authorization and notification resources for state-specific requirements.

The policy emphasizes that medical records documentation may be required to assess whether members meet clinical criteria but that such documentation does not guarantee coverage.

Key Evidence Items

Professional Society Positions

Definitions and Thresholds

Term	Definition
External Nasal Valve
Includes caudal edge of lateral crus of lower lateral cartilage, soft tissue alae, membranous septum, and sill of the nostril; entrance to the nose.
Mechanical Nasal Airway Obstruction
Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.
Prolonged, Persistent Nasal Airway Obstruction
Nasal obstruction not responsive to 6 weeks of medical management such as nasal steroids, antihistamines, and decongestants; excludes drug-induced rhinitis.
NOSE
Nasal Obstruction Symptom Evaluation score (patient-reported outcome measure for nasal obstruction).
rTNSS / TNSS
(reflective) Total Nasal Symptom Score, composite patient-reported scale for nasal symptoms including rhinorrhea, congestion, sneezing, itching.
Responder
Study-specific; commonly defined as ≥30% reduction in TNSS/rTNSS or ≥20-point reduction or one NOSE severity class improvement.
rTNSS
Reflective Total Nasal Symptom Score — validated patient-reported symptom scale for rhinitis.
NOSE Scale
Nasal Obstruction Symptom Evaluation — validated questionnaire for nasal airway obstruction severity.
MCID
Minimum clinically important difference.
External Nasal Valve (updated)
Definition updated in this revision (text not included in this part).

Quick-reference thresholds

Prolonged, Persistent Nasal Airway ObstructionFailure to respond to 6 weeks of medical therapy (intranasal steroids, antihistamines, decongestants)

NOSE baseline examplesStudy examples: mean NOSE 76.7 (San Nicoló); many TCRF nasal valve cohorts required NOSE >=60 or had means ~76–80

rTNSS / TNSS baseline threshold>= 6 total rTNSS used for eligibility in multiple PNN/chronic rhinitis trials

rTNSS subscores (eligibility examples)Rhinorrhea subscore 2–3; Congestion 1–3; Itching/sneezing 0–3 (examples from Ehmer, Takashima)

Responder definitions>=30% reduction in TNSS/rTNSS (PNN/cryo studies); NOSE responder often >=20-point reduction or >=1 severity class improvement

Silvers (TCRF nasal valve) responder

Revision History

2026-05-01material_changeLatest

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and applicable laws; documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; medical records must fully support medical necessity and be legible and available upon request.