Rhinoplasty and Other Nasal Surgeries
CLINICAL POLICY
RHINOPLASTY AND OTHER NASAL SURGERIES
Policy Number: ENT 005.16 T2
Effective Date: August 1, 2015
Table of Contents
CONDITIONS OF COVERAGE .................................
…………………………..
COVERAGE RATIONALE ………………………………
DEFINITIONS …………………………………………….
APPLICABLE CODES ...............................................
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Related Policies:
Cosmetic and
Reconstructive
Procedures
Orthognathic (Jaw)
Surgery
Plagiocephaly and
REFERENCES ..........................................................
POLICY HISTORY/REVISION INFORMATION ..........
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Craniosynostosis
Treatment
Policy History Revision Information
The services described in Oxford policies are subject to the terms, conditions and limitations of the
Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare
Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law.
The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.
CONDITIONS OF COVERAGE
Applicable Lines of
Business/ Products
This policy applies to Oxford Commercial plan membership
Benefit Type
Referral Required
(Does not apply to non-gatekeeper products)
General benefits package
No
Authorization Required
( Precertification always required for inpatient admission)
Precertification with Medical
Director Review Required
Applicable Site(s) of Service
(If site of service is not listed, Medical
Director review is required)
Special Considerations
Yes
Yes
Outpatient, Office
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Precertification with review by a Medical Director or their designee may be required.
Rhinoplasty and Other Nasal Surgeries: Clinical Policy (Effective 08/01/2015)
©1996-2015, Oxford Health Plans, LLC
BENEFIT CONSIDERATIONS
Before using this guideline, please check the member specific plan document and any federal or state mandates, if applicable.
Essential Health Benefits for Individual and Small Group:
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this guideline, it is important to refer to the member specific benefit document to determine benefit coverage.
COVERAGE RATIONALE
Some states require benefit coverage for services that UnitedHealthcare considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to enrollee’s plan specific documents.
Indications for Coverage
Rhinoplasty for Nasal Vestibular Stenosis or Alar Collapse
Repair of nasal vestibular stenosis or alar collapse is considered reconstructive and medically necessary when all of the following criteria are present:
A. Prolonged, persistent obstructed nasal breathing due to internal and/or external nasal valve compromise (see definition below), and
B. Internal valve compromise due to collapse of the upper lateral cartilage and/or external nasal valve compromise due to collapse of the alar (lower lateral) cartilage resulting in an anatomic mechanical nasal airway obstruction that is a primary contributing factor for obstructed nasal breathing. and
C. Other causes have been eliminated as the primary cause of nasal obstruction (eg. sinusitis, allergic rhinitis, vasomotor rhinitis, nasal polyposis, adenoid hypertrophy, nasopharyngeal masses)
Rhinoplasty for Congenital Anomalies
The following are considered reconstructive and medically necessary when the following criteria are present:
Rhinoplasty is considered reconstructive when performed for a nasal deformity associated with congenital craniofacial anomalies including, but not limited to Pierre Robin, Apert Syndrome,
Fraser Syndrome, Binder Syndrome, Goldenhar Syndrome, Nasal dermoids, Tessier Nasal Cleft
(most commonly #1) or associated with a cleft lip or cleft palate.
Septal Dermatoplasty (CPT 30620):
Septal dermatoplasty is considered reconstructive when:
A. There is a documented functional impairment (eg. Obstruction, pain or bleeding) due to diseased nasal mucosa, and
B. The functional impairment will be eliminated by a skin graft.
Lysis Intranasal Synechia (CPT 30560):
Lysis intranasal synechia is considered reconstructive when:
Rhinoplasty and Repair of Vestibular Stenosis: Clinical Policy (Effective 08/01/2015)
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A. There is a documented functional impairment (eg. Obstruction, pain or bleeding) due to intranasal synechia (adhesions/scar bands), and
B. The functional impairment will be eliminated by lysis of the synechia.
Medical Necessity Plans: Please use the criteria above where applicable.
Documentation:
Rhinoplasty or other nasal surgery documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made. The enrollee’s medical record must contain, and be available for review on request, the following information:
Physician office notes
Radiologic imaging
Photographs that document the nasal anomaly
Coverage Limitations and Exclusions
Cosmetic Procedures are excluded from coverage, including but not limited to:
A. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered
Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure.
B. Rhinoplasty, unless rhinoplasty criteria above are met.
C. Any procedure that does not meet the reconstructive criteria above.
D. Rhinoplasty procedures performed to improve appearance. (check enrollee’s plan specific document)
DEFINITIONS
Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth.
External Nasal Valve, NARES = Lateral Crus (wing) of the lower lateral (alar) cartilage.
Functional/Physical Impairment : A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life function.
Reconstructive Surgery : Defined by the American Society of Plastic Surgeons, 'is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Septal Dermatoplasty: The physician removes diseased intranasal mucosa and replaces it with a separately reportable split thickness graft. The surgery is performed on one nasal side. A lateral rhinotomy is made to expose the intranasal mucosa. The diseased mucosal tissue is excised from the septum, nasal floor, and anterior aspect of the inferior turbinate. A split thickness graft is sutured to the recipient bed, covering the exposed cartilage and submucosal surfaces. Gauze packing and splints are placed in the grafted nasal cavity.
Synechia : an adhesion of parts, typically the nasal side wall to the septum.
Rhinoplasty and Repair of Vestibular Stenosis: Clinical Policy (Effective 08/01/2015)
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APPLICABLE CODES
The Current Procedural Terminology (CPT
®
) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply. This list of codes may not be all inclusive.
CPT
® is a registered trademark of the American Medical Association.
IMPORTANT: All nasal surgical cases may be subject to coding review.
Rhinoplasty Repair
CPT
®
Code
30400
Description
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
30430
30435
30450
30460
Rhinoplasty, primary; including major septal repair
Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip only
30462
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip, septum, osteotomies
Surgical Repair of Vestibular Stenosis
CPT
®
Code Description
30465
Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)
Miscellaneous Codes
CPT
®
Code Description
30540
30545
Repair choanal atresia; intranasal
Repair choanal atresia; transpalatine
30560
30620
Lysis intranasal synechia
Septal or other intranasal dermatoplasty (does not include obtaining graft)
BACKGROUND
Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinates. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures, and incision or excision of the overlying skin of the nose.
Rhinoplasty is a surgical procedure to change the appearance of the nose, alter the width of the nostrils and/or change the angle between the nose and the upper lip. It is performed alone or in combination with other procedures, such as septoplasty and turbinoplasty, to correct deformities that result from nasal trauma, either acquired or iatrogenic, airway obstruction related to septal and bony deviations, turbinate hypertrophy or congenital defects. All of the Rhinoplasty procedures are intended solely to alter appearance and are unlikely to be approved as reconstructive.
Turbinate Resection is a surgical procedure often performed along with a septoplasty to correct the turbinate which is a structure that projects from the lateral wall of the nose into the nasal
Rhinoplasty and Repair of Vestibular Stenosis: Clinical Policy (Effective 08/01/2015)
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cavity. Since this these treatments may be potentially cosmetic, clinical criteria must be met before they can be considered for coverage; therefore, precertification and medical director review is required in order to determine whether the procedure is reconstructive, and medically necessary.
REFERENCES
The foregoing Oxford policy has been adapted from a UnitedHealthcare Coverage Determination
Guideline that was researched, developed and approved by the UnitedHealthcare Coverage
Determination Committee [CDG.019.04].
1. American Society of Plastic Surgeons (ASPS) available @: http://www.plasticsurgery.org/
2. MCG Care Guidelines, Ambulatory Care 19th Edition, 2015. Rhinoplasty: ACG: A-0184 (AC).
3. Goiato MC, Dos Santos DM, Fajardo RS, de Carvalho Dekon SF. Solutions for nasal defects.
Journal of Craniofacial Surgery 2009;20(6):2238-41. DOI: 10.1097/SCS.0b013e3181bf858c.
4. International Forum Allergy and Rhinology. Volume 3. January 2013.
5. Peters AT, Spector S, Hsu J, et al. Diagnosis and Management of Rhinosinusitis: A Practice
Parameter Update, 2014-a0-01Z, Volume 113, Issue 4, Pages 347-385, Copyright 2014
American College of Allergy, Asthma & Immunology.
POLICY HISTORY/REVISION INFORMATION
Date Action/Description
Changed policy title; previously titled Rhinoplasty and Repair of
Vestibular Stenosis
Revised coverage rational/indications for coverage:
Rhinoplasty for Nasal Vestibular Stenosis or Alar Collapse o Updated coverage criteria for reconstructive/medically
08/01/2015 necessary treatment:
Removed criterion requiring “internal and/or external nasal valve compromise causes an anatomic mechanical nasal airway obstruction and is a primary contributing factor for obstructed nasal breathing (e.g., large cutaneous defect, malignancy or trauma)”
Added criterion requiring “internal valve compromise due to collapse of the upper lateral cartilage and/or external nasal valve compromise due to collapse of the alar (lower lateral) cartilage resulting in an anatomic mechanical nasal airway obstruction that is a primary contributing factor for obstructed nasal breathing”
Rhinoplasty for Congenital Anomalies o Reworded coverage criteria for reconstructive/medically necessary treatment to indicate r hinoplasty is considered reconstructive when performed for a nasal deformity associated with congenital craniofacial anomalies including, but not limited to Pierre Robin, Apert Syndrome, Fraser
Syndrome, Binder Syndrome, Goldenhar Syndrome, Nasal dermoids, Tessier Nasal Cleft (most commonly #1) or associated with a cleft lip or cleft palate
Septal Dermatoplasty (new to policy) o Added language to indicate septal dermatoplasty (CPT code 30620) is considered reconstructive when;
There is a documented functional impairment (e.g.,
Rhinoplasty and Repair of Vestibular Stenosis: Clinical Policy (Effective 08/01/2015)
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obstruction, pain or bleeding) due to diseased nasal mucosa, and
The functional impairment will be eliminated by a skin graft
Lysis Intranasal Synecha (new to policy) o Added language to indicate lysis intranasal synechia (CPT code 30560) is considered reconstructive when;
There is a documented functional impairment (e.g., obstruction, pain or bleeding) due to intranasal synechia
(adhesions/scar bands), and
The functional impairment will be eliminated by lysis of the synechia
Documentation (new to policy) o Added language to indicate r hinoplasty or other nasal surgery documentation should include the evaluation and management note for the date of service and the note for the day the decision to perform surgery was made; the enrollee’s medical record must contain, and be available for review on request, the following information:
Physician office notes
Radiologic imaging
Photographs that document the nasal anomaly
Updated definitions; added definition of: o
External nasal valve o
Septal dermatoplasty o Synechia
Archived previous policy version ENT 005.15 T2
Rhinoplasty and Repair of Vestibular Stenosis: Clinical Policy (Effective 08/01/2015)
©1996-2015, Oxford Health Plans, LLC
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