Rhinoplasty and septorhinoplasty These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. Administrative Process Prior authorization is not required for: • Septoplasty • Surgical repair of vestibular stenosis • Rhinoplasty, when it is done to repair a nasal deformity caused by cleft lip/ cleft palate Prior authorization is required for: • Rhinoplasty for any indication other than cleft lip/ cleft palate • Septorhinoplasty Coverage Rhinoplasty is not covered for cosmetic reasons to improve the appearance of the member, but may be covered subject to the criteria listed below and per your plan documents. The service and all related charges for cosmetic services are member responsibility. Indications that are covered 1. Primary rhinoplasty (30400, 30410) may be considered medically necessary when all of the following are met: A. There is anatomical displacement of the nasal bone(s), septum, or other structural abnormality resulting in mechanical nasal airway obstruction, and B. Documentation shows that the obstructive symptoms have not responded to at least 3 months of conservative medical management, including but not limited to nasal steroids or immunotherapy, and C. Photos clearly document the structural abnormality as the primary cause of the nasal airway obstruction, and D. Documentation includes a physician statement regarding why a septoplasty would not resolve the airway obstruction. 2. Secondary rhinoplasty (30430, 30435, 30450) may be considered medically necessary when: A. The secondary rhinoplasty is needed to treat a complication/defect that was caused by a previous surgery (when the previous surgery was not cosmetic), and B. The previous surgery was needed because of an anatomical mechanical nasal airway obstruction caused by injury/ trauma, malignancy, or congenital defect other than cleft lip/ cleft palate. 3. Septorhinoplasty (30420) may be considered medically necessary when all of the following are met: A. There is anatomical displacement of the nasal bone(s), septum, or other structural abnormality resulting in mechanical nasal airway obstruction, and B. Documentation shows that the septal deviation, obstruction or deformity has not responded to conservative medical management, including but not limited to nasal steroids or immunotherapy, and C. Photos clearly document the structural abnormality as the primary cause of the nasal airway obstruction, and D. Documentation includes a physician statement regarding why a septoplasty would not resolve the airway obstruction. 4. Surgical repair of weakened external valves to treat nasal airway obstruction is covered. 5. Requests for reconstructive repair which do not meet the criteria in this policy will be reviewed on a case by case basis using HealthPartners Reconstructive Policy criteria (see link at right). Requests which do not meet Reconstructive criteria are considered cosmetic. Indications that are not covered 1. The following procedures (not all-inclusive) are not covered as they are not typically required to correct a functional nasal airway obstruction and are considered cosmetic: A. Dorsal hump removal B. Shortening of the nasal septum C. Narrowing of the bony pyramid D. Correction of saddle nose deformity 2. Cosmetic rhinoplasty done alone, or in combination with, a septoplasty. Definitions Primary rhinoplasty is the initial rhinoplasty surgery. Rhinoplasty is surgery performed to make changes to the internal and external structures of the nose. This may be done to improve appearance (cosmetic rhinoplasty) or to restore the ability to breathe through the nose (functional rhinoplasty). Reconstructive surgery is surgery, incidental to or following surgery, resulting from injury or illness of the involved body part. (Please refer to the separate Reconstructive Surgery policy.) Secondary rhinoplasty is a subsequent rhinoplasty surgery. Septoplasty is surgical repair of the nasal septum. The septum is the internal wall that divides the nasal cavities. Septorhinoplasty is the term for rhinoplasty and septoplasty surgeries performed together. It involves operating on the bones and cartilage that give the nose its shape and structure (rhinoplasty) and straightening the septum (septoplasty). Surgical repair of vestibular stenosis is surgery to repair collapsed internal valves by placement of a spreader graft, or a batten graft to treat nasal airway obstruction. Codes If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive. The services associated with these codes require prior authorization: Codes Description 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) The services associated with these codes do not require prior authorization: Codes Description 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 (eg, spreader grafting, lateral nasal wall reconstruction 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Products This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645. Medical Director Committee Approval 03/09/2000; Revised 11/27/01, 10/31/17, 12/29/17, 7/26/19; Annual Review 06/01/06, 8/1/07, 8/1/08, 9/9/09, 9/28/10, 9/2011, 9/2012, 9/2013, 9/2014, 10/2015, 9/2016, 9/2017, 7/2018, 7/2019, 7/2020, 7/2021 References 1. American Cleft Palate-Craniofacial Association. Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial differences. Chapel Hill (NC): American Cleft Palate-Craniofacial Association; May 1993, Rev. 2018. doi: 10.1177/1055665617739564 2. Anastassov, G.E., Joos, U., & Zollner, B. (1998). Evaluation of the results of delayed rhinoplasty in cleft and palate patients. British Journal of Oral and Maxillofacial Surgery, 36, 416-424. 3. Ardeshirpour, F., McCarn, K.E., McKinney, A.M., Odland, R.M., Yueh, B.Y., & Hilger, P.A. (2016). Computed tomography scan does not correlate with patient experience of nasal obstruction. The Laryngoscope, 126(4), 820-825. 4. Constantian, M. B., Clardy, R. B. (1996). The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plastic and Reconstructive Surgery, 98(1), 38-54. 5. DeFatta, R. J., Ducic, Y., Adelson, R. T., & Sabatini, P. R. (2008). Comparison of closed reduction alone versus primary open repair of acute nasoseptal fractures. Journal of Otolaryngology-Head & Neck Surgery, 37(4), 502–506. 6. Han, J. K., Stringer, S. P., Rosenfeld, R. M., Sanford, M. A., Baker, D. P., Brown, S. M., … Nnacheta, L. C. American Academy of Otolaryngology—Head and Neck Surgery Foundation. (2015). Clinical consensus statement: Septoplasty with or without inferior turbinate reduction. Otolaryngology–Head and Neck Surgery, 153(5) 708–720. 7. Ishii, L.E., Tollefson, T.T., Basura, G.J., Rosenfeld, R.M., Abramson, P.J., Chaiet, S.R.,… Nnacheta, L.C. American Academy of Otolaryngology-Head and Neck Surgery Foundation. (2017). Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty. Otolaryngology-Head and Neck Surgery, 156(2S), S1-S30. 8. Moore, M. & Eccles, R. (2011). Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clinical Otolaryngology, 36, 106-113. 9. Rhee J. S., Arganbright J. M., McMullin B. T., & Hannley M. (2008). Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngology–Head and Neck Surgery, 139(1), 10-20. 10. Rhee, J. S., Weaver, E. M., Park, S. S., Baker, S. R., Hilger, P. A., Kriet, J. D., … DiVittorio, D. American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2010). Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngology–Head and Neck Surgery, 143, 48-59. 11. Spielmann, P. M.., White, P. S., & Hussain, S. S. M. (2009). Surgical techniques for the treatment of nasal valve collapse: a systematic review. The Laryngoscope, 119: 1281-1290. .