CPT Code Description
Rhinoplasty
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 columnar lengthening; tip only
30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columnar lengthening; tip, septum, osteotomies Repair of Vestibular Stenosis
30465 Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)
Rhinophyma
30120 Excision or surgical planing of skin of nose for rhinophyma Lysis Intranasal Synechia
30560 Lysis intranasal synechia Septal Dermatoplasty
30620 Septal or other intranasal dermatoplasty (does not include obtaining graft)
RHINOPLASTY AND OTHER NASAL SURGERIES
INSTRUCTIONS FOR USE
This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.
When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
CONDITIONS OF COVERAGE
Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.
Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
No
Authorization Required
(Precertification always required for inpatient admission) Yes
Precertification with Medical Director Review Required Yes1 Applicable Site(s) of Service
(If site of service is not listed, Medical Director review is required)
Outpatient, Office
Special Considerations 1Precertification with review by a Medical Director or their designee may be required.
BENEFIT CONSIDERATIONS
Before using this policy, please check the member specific benefit 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, 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 policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.
COVERAGE RATIONALE
Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.
Indications for Coverage
Rhinoplasty-Primary (CPT 30410, 30420)
Rhinoplasty-primary is considered reconstructive and medically necessary when all of the following criteria are present:
** Prolonged, persistent obstructed nasal breathing due to nasal bone and septal deviation that are the primary causes of an anatomic mechanical nasal airway obstruction, and
** The nasal airway obstruction cannot be corrected by septoplasty alone as documented in the medical record, and
** Photos clearly document the nasal bone/septal deviation as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and
** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway
obstruction by centralizing the nasal bony pyramid (30410) and also straightening the septum (30420), and
** One of the following is present:
o Nasal fracture with nasal bone displacement severe enough to cause nasal airway obstruction, or
o Residual large cutaneous defect following resection of a malignancy or nasal trauma, and
** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and
** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.
Rhinoplasty-Tip (CPT 30400)
Rhinoplasty-tip is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:
** Prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic mechanical nasal airway obstruction (this code is usually cosmetic), and
** Photos clearly document tip drop as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam (acute columellar-labial angle), and
** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by lifting the nasal tip, and
** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and
** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.
Rhinoplasty-Secondary (CPT 30430, 30435, 30450)
Rhinoplasty-secondary is primarily cosmetic. However, it is considered reconstructive and medically necessary when all of the following criteria are present:
** Required as treatment of a complication/residual deformity from primary surgery performed to address a functional impairment when a documented functional impairment persists due to the complication/deformity (these codes are usually cosmetic), and
** Photos clearly document the secondary deformity/complication as the primary cause of an anatomic mechanical nasal airway obstruction and are consistent with the clinical exam, and
** The proposed procedure is designed to correct the anatomic mechanical nasal airway obstruction and relieve the nasal airway obstruction by correcting the deformity or treating the complication. (These codes are usually cosmetic), and
** Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing), and
** Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.
DEFINITIONS
When applicable, please refer to the member specific benefit plan document for 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. Mechanical Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.
Prolonged, Persistent Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants.
Elimination of rhinitis medicamentosa as a cause for airway obstruction.
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. Rhinitis Medicamentosa (RM): A condition of rebound nasal congestion brought on by extended use of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal sprays) and certain oral medications (e.g., sympathomimetic amines and various 2-imidazolines) that constrict blood vessels in the lining of the nose.
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.
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