ModifiedUnitedHealthcarePolicy CS107KS.02

Rhinoplasty and Other Nasal Procedures (for Kansas Only)

Defines medical necessity and coverage criteria for nasal surgeries including nasal valve repair, rhinophyma excision, rhinoplasty, and related procedures for UnitedHealthcare Community Plan members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyRhinoplasty and Other Nasal Procedures (for Kansas Only)

Policy CodePolicy CS107KS.02

Change TypeRemoved CPT 30999; documentation clarifications; definition and evidence updates

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionObtain and submit complete, legible medical records and photos documenting anatomy, symptom duration, prior conservative therapy, and baseline validated symptom scores to support prior authorization and medical necessity.

SourceLink

POLICY UPDATE CHANGES

Removed CPT code 30999.

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and listing examples of required documentation.

Updated definition of 'External Nasal Valve'.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

Kansas-onlystate-specific applicability

90%subjective satisfaction in study

117RCT size (Silvers et al.)

88% vs 42%

3‑month responder (active vs sham)

low–fairevidence quality noted

Coverage Criteria and Evidence Summary

inv cu-02: Rhinophyma excision — covered when ALL of the following are met

Rhinophyma excision — covered when ALL of the following are met:

The member has one of the following: (a) prolonged, persistent obstructed nasal breathing due to rhinophyma; or (b) chronic infection or bleeding unresponsive to medical management due to rhinophyma.

Photos clearly document rhinophyma as the primary cause of an anatomical mechanical nasal airway obstruction or chronic infection and are consistent with the clinical examination.

The proposed procedure is designed to correct the anatomical mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity, or the proposed procedure is designed to address the chronic infection.

inv cu-06: Unproven procedures — not medically necessary

Unproven procedures — considered not medically necessary due to insufficient evidence of safety and/or efficacy:

Absorbable polylactic acid nasal cartilage support implants (for example, Latera Absorbable Nasal Implant) for supporting upper and lower lateral cartilage.

Nasal septal swell body (NSB) reduction for the treatment of nasal obstruction.

Posterior nasal nerve (PNN) or sphenopalatine ganglion (SPG) ablation by any method (e.g., radiofrequency, cryoablation; examples include RhinAer®, ClariFix™) for the treatment of chronic rhinitis.

Radiofrequency treatment of nasal valves for treatment of nasal airway obstruction (for example, VivAer® ARC Stylus).

Billing Codes and Coding Guidance

Applicable CPT Codes (part 1)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).

Applicable CPT Codes (part 2)CPT

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.
30465	Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction).
30468	Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s).
30469	Repair of nasal valve collapse with low energy, temperature-controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling.
31237	Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure).
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.
64999	Unlisted procedure, nervous system

Applicable HCPCS CodesHCPCS

L8699

Prosthetic implant, not otherwise specified

Covered CPT Codes, Not Covered, Experimental, Cosmetic, Presumptivemixed

No codes listed

FDA product codes / device contextmixed

LRC	FDA product code category: instrument; ear, nose, and throat (ENT); manual surgical (510(k) exempt)

Removed CPT CodesCPTNot Covered

30999

Unlisted procedure, nose — removed from Applicable Codes in this policy

Conservative management duration

Conservative management durationTypically 4–6 weeks of documented conservative medical therapy (eg, intranasal corticosteroids, antihistamines) prior to surgical consideration

Rhinoplasty pediatric referencePolicy notes conservative management of at least 4 weeks for some pediatric rhinoplasty indications

'Prolonged, Persistent' definitionPolicy defines 'Prolonged, Persistent Nasal Airway Obstruction' as lack of response to 6 weeks of medical management

NOSE score responder definition

NOSE responder — definition used in San Nicoló and related studies

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization and Documentation Expected

Prior authorization may be required for nasal surgical procedures; medical records documentation should be provided to support medical necessity. All nasal surgical claims may be subject to coding review to determine reconstructive vs cosmetic intent.

PA implied for listed nasal surgical codes (see Applicable Codes) — submit clinical documentation with request
Medical records must be legible and available upon request

Note

Prior Authorization — Not Always Explicit

Prior authorization is not explicitly specified for every procedure in the excerpt; however, requests for procedures addressing nasal airway obstruction (NAO) due to valve collapse should include documentation of the cause and baseline symptom severity to allow coverage determination.

Key Terms and Definitions

External Nasal Valve — anatomical definition

Anatomic componentsExternal nasal valve includes caudal edge of lateral crus of lower lateral cartilage, soft tissue alae, membranous septum, and nostril sill

Functional descriptionIt is the entrance to the nose and contributes to external nasal airflow dynamics

Source referenceDefinition cited to Totonchi et al., 2024 in policy definitions section

Mechanical Nasal Airway Obstruction — definition

DefinitionMechanical nasal airway obstruction: difficulty breathing through the nose (not snoring) caused by a bony or cartilaginous deformity

ExamplesMay be due to septal deviation, turbinate hypertrophy, or valve collapse

Clinical Background and Context

Mechanical nasal airway obstruction refers to difficulty breathing through the nose due to bony or cartilaginous deformity. Nasal valve compromise (internal or external) and rhinophyma can produce obstruction; evaluation typically includes physical examination with maneuvers (e.g., modified Cottle), photographic documentation of anatomy and dynamic collapse, and assessment of response to conservative medical therapy prior to consideration of reconstructive procedures.

Policy Revision History

06/01/2026material_changeLatest

Added and clarified medical records documentation requirements for reviews, including that documentation must fully support medical necessity, be legible, maintained in the patient record, and available upon request; noted that providing documentation does not guarantee coverage and that benefit coverage is determined by federal, state, or contractual requirements.

06/01/2026revised_code_list

Removed CPT code 30999 from the Applicable Codes list in this policy.

06/01/2026updated_definition

Policy Summary

PayerUnitedHealthcare

PolicyRhinoplasty and Other Nasal Procedures (for Kansas Only)

Policy CodePolicy CS107KS.02

Change TypeRemoved CPT 30999; documentation clarifications; definition and evidence updates

Effective DateJune 1, 2026

Next Review DateN/A

SourceLink

On This Page

Responder = at least one NOSE clinical severity class improvement or ≥20% reduction in NOSE score

San Nicoló responder rate contextSan Nicoló study defined responders this way and reported ~76% responder rate at 12 months

Trial endpoint consistencySame NOSE responder definition was used as primary endpoint in randomized TCRF nasal valve trials

San Nicoló inclusion NOSE threshold

San Nicoló inclusion thresholdStudy enrolled participants with baseline NOSE scores ≥55

Baseline severity in San NicolóMean preoperative NOSE score reported as 76.7 (range 55–100)

SettingParticipants had isolated nasal valve collapse as primary contributor to NAO

rTNSS responder threshold used in trials (eg ≥30% reduction)

rTNSS responder thresholdResponder commonly defined in trials as ≥30% reduction in rTNSS from baseline

Example RCT endpointStolovitzky and Del Signore trials used ≥30% rTNSS reduction at 3 months as primary responder definition

Meta-analysis contextSystematic reviews and meta-analyses report responder rates using the ≥30% rTNSS threshold

rTNSS baseline eligibility (>= 6)

rTNSS baseline eligibilityMany trials required baseline rTNSS ≥ 6 for enrollment

Symptom duration requirementTrials generally enrolled patients with chronic rhinitis symptoms ≥6 months

Subscore requirementsSome trials required minimum subscores (eg, rhinorrhea subscore 2–3; congestion subscore 1–3)

NOSE Scale baseline used in some trials (>= 60)

NOSE Scale baseline used in several valve studiesSome nasal valve studies enrolled participants with baseline NOSE Scale scores ≥60

Example cohort baselineYao et al. prospective cohort required baseline NOSE ≥60 and reported mean baseline NOSE ~80.3 in completers

RCT baseline contextSilvers et al. RCT participants had mean baseline NOSE scores in the mid‑70s to high‑70s

If PA is not specifically required by plan documents, documentation may still be requested during claim review
Submit photos, exam findings, and validated baseline scores (e.g., NOSE, rTNSS) with any request

Documentation Required

Prior Authorization: Document NAO Due to Valve Collapse and Baseline NOSE

When seeking authorization for procedures to treat NAO due to nasal valve collapse, document that NAO is due primarily to valve collapse and include a baseline NOSE score and objective/photographic evidence of dynamic or static valve compromise.

Document visible collapse of alar cartilage and/or lateral nasal wall with deep inspiration
Include modified Cottle maneuver findings and photos demonstrating dynamic collapse
Include baseline NOSE Scale (and follow-up plans) in the medical record

Documentation Required

Procedures Using Absorbable Nasal Cartilage Support Implants

Procedures using absorbable nasal cartilage support implants (e.g., Latera) should be documented with indication that dynamic nasal valve collapse is a main contributor to NAO and that patients have undergone appropriate stepwise management prior to implant placement.

Describe device used (Latera is the FDA-approved absorbable implant) and that insertion is via minimally invasive intranasal approach
Provide rationale for implant versus alternative surgical options and note any concurrent procedures

Note

Evidence Quality and Follow-up Limitations

Available evidence for absorbable nasal implants and some valve/radiofrequency procedures is promising but overall of low quality with inadequate long-term follow-up and limitations in study design.

Many studies have short follow-up (often 3–12 months) or lack robust control arms
Single-center, small-sample, or nonrandomized designs are common

Denial Risk

Evidence Limitations May Trigger Additional Documentation or Denials

Limitations in the evidence base (short follow-up, lack of controls, risk of bias) may lead UnitedHealthcare to request additional documentation or to deny coverage when medical necessity cannot be adequately demonstrated.

Lack of objective measures or comparator groups can increase denial risk
Significant loss to follow-up in studies reduces certainty about durability

Denial Risk

Evidence Insufficiency Risk

Evidence insufficiency (high risk of bias, short-term outcomes only, or inconclusive clinical impact) creates a higher risk that requests for novel or less-established interventions will be restricted or denied unless robust supporting documentation is provided.

Provide long-term outcome data where available and clearly document objective measures and symptom scores
If evidence is limited, include rationale for why alternative treatments are unsuitable or have failed

Step Therapy

Treatment Sequencing Considerations

Treatment sequencing should be evident in the record: evaluate and treat other causes of nasal obstruction and attempt appropriate conservative therapies before invasive procedures. When multiple anatomic contributors exist, sequence or combine treatments as clinically indicated.

Ensure other causes (rhinosinusitis, polyposis, turbinate hypertrophy, septal deviation) have been addressed or are planned for concurrent correction
Document rationale for proceeding with valve-focused procedure when coexisting pathology exists

Note

Society Guidance Supports Use of FDA‑Approved Biomaterials

Society guidance (AAO-HNS, ARS) supports the use of FDA‑approved biomaterials such as bioabsorbable implants in selected patients and recommends clinician judgment guided by evidence, experience, and patient preference.

AAO-HNS recognizes surgical repair options including implants and emphasizes treating other causes of NAO to optimize outcomes
AAO-HNS (2025) supports use of FDA-approved biomaterials in sinonasal procedures when clinically appropriate
ARS (2022) supports bioabsorbable implants as an effective option for NAO due to valve collapse in selected patients

Step Therapy

Stepwise Therapy Expectation

Stepwise therapy is expected: document adequate conservative medical management and failure of appropriate medical therapies (eg, intranasal steroids, antihistamines, anticholinergics) prior to device-based or surgical interventions when clinically indicated.

Conservative management duration often described as ≥4 weeks (or longer per specific indication); for chronic rhinitis trials often >6 months with defined rTNSS thresholds
For PNN procedures, document failed medical management including topical agents and duration

Documentation Required

Medical Records and Documentation Requirements

Medical records documentation may be requested during review and must fully support the medical necessity of the requested service. Documentation should include history, physical exam, diagnostic testing, validated symptom scores, photographs, and a clear surgical plan indicating why the proposed intervention is needed.

Records must be legible and available upon request
Include baseline and follow-up NOSE and/or VAS scores when applicable, modified Cottle maneuver findings, and photographic evidence of valve collapse

Diagnostic focusClinical exam and maneuvers (eg, modified Cottle) identify mechanical contributors

Prolonged, Persistent Nasal Airway Obstruction — definition

Definition of prolonged/persistent NAONasal airway obstruction that has not responded to 6 weeks of medical management (eg, nasal steroids, antihistamines, decongestants)

Exclusion of drug-induced rhinitisPolicy specifies elimination of drug‑induced rhinitis (eg, rhinitis medicamentosa) as a cause before labeling as prolonged/persistent

Implication for treatmentUsed as a criterion to consider surgical intervention when obstruction persists after appropriate medical therapy

Absorbable nasal cartilage support implant — definition and intended action

DefinitionAbsorbable nasal cartilage support implant: synthetic polylactic acid nasal graft that absorbs over ~2 years and leaves a collagen track to support the nasal valve (example: Latera)

Intended actionInserted via minimally invasive approach to support upper and lower lateral cartilage and reduce nasal airway obstruction by reinforcing the lateral nasal wall

Regulatory noteLatera is the only FDA‑cleared absorbable nasal implant referenced in the policy

Nasal septal swell body (NSB) — definition and synonyms

DefinitionNasal septal swell body (NSB): a thickened mucosal region of the anterior nasal septum, superior to the inferior turbinate and anterior to the middle turbinate

SynonymsAlso called nasal septal turbinate, septal turbinate, Kiesselbach body, septal swell body, nasal septal body, septal erectile body, among others

Clinical relevanceEnlargement can impact nasal resistance and contribute to nasal obstruction; targeted in reduction procedures

Bioabsorbable nasal implant — definition (eg Latera)

DefinitionBioabsorbable nasal implant: an implant (eg, polylactic acid copolymer such as Latera) placed to support the lateral nasal wall to treat dynamic nasal valve collapse

Placement and purposeInserted through a small incision in office or operating room to provide cantilever support to lateral cartilage and reduce NAO

Absorption timeframeImplant material absorbs over approximately two years, leaving a collagen track

Septal Swell Body Reduction (SSBVR) — definition and techniques

DefinitionSeptal Swell Body Reduction (SSBVR): procedures (eg, TCRF, radiofrequency ablation, coblation, microdebridement) targeting hypertrophy of the septal swell body to reduce obstruction

TechniquesApproaches include temperature‑controlled radiofrequency (TCRF, e.g., VivAer), RFA, coblation, microdebrider‑assisted submucosal reduction, or combinations with turbinate surgery

Evidence noteStudies show symptomatic and size reductions up to 12 months but are limited by small samples and short follow-up

Septal body / NSB / NST — definition and context

Septal body / NSB / NST — definitionAn anatomic septal region (nasal septal swell body or nasal septal turbinate) that may be hypertrophied and contribute to nasal obstruction

Treatment targetsTargeted by submucosal resection, coblation, RFA, microdebrider procedures, often combined with turbinate surgery

Clinical evidenceEvidence is limited by small studies and short follow-up; further RCTs needed to define long‑term benefit

Posterior nasal nerve (PNN) ablation / RhinAer / ClariFix — definition and examples

DefinitionPosterior nasal nerve (PNN) ablation: minimally invasive procedures (eg, TCRF neurolysis with RhinAer or cryoablation with ClariFix) targeting the PNN/SPG region to reduce chronic rhinitis symptoms

Examples of devices/techniquesRhinAer (TCRF neurolysis) and ClariFix (cryoablation) are described as examples used in trials and studies

Intended outcomesAimed to reduce rhinorrhea, congestion, sneezing, and other chronic rhinitis symptoms with responder endpoints based on rTNSS reductions

Responder (rTNSS) — trial responder definition (≥30% reduction)

Responder (rTNSS) definitionIn trials, a responder for chronic rhinitis commonly defined as ≥30% reduction in rTNSS from baseline at follow‑up (eg, 90 days)

Trial examplesDel Signore and Stolovitzky RCTs used the ≥30% rTNSS responder definition for primary end points

Reported responder ratesRCTs and meta-analyses report responder rates often in the range of ~57–80% depending on follow-up and study design

Responder (NOSE) — nasal valve responder definition (≥20% improvement or class improvement)

Responder (NOSE) definitionFor nasal valve studies, a responder is defined as ≥20% improvement in NOSE Scale score or at least one clinical severity class improvement

RCT exampleSilvers et al. RCT used this NOSE responder definition and reported significantly higher responder rates for active TCRF vs sham at 3 months

Clinical applicationUsed as primary efficacy endpoint in multiple nasal valve and SSBVR studies reported in the policy

External Nasal Valve — updated definition (policy update)

Updated definition notedPolicy history documents an updated definition of 'External Nasal Valve' in the June 1, 2026 revision

Current anatomical definitionExternal nasal valve includes caudal edge of lateral crus, soft tissue alae, membranous septum, and nostril sill (see Definitions)

Documentation updatePolicy revision also clarified documentation expectations related to medical record content and availability upon request

Updated definition of 'External Nasal Valve' in the Definitions section.

06/01/2026updated_content

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.