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Medical Policy: 07.01.29
Original Effective Date: October 2005
Reviewed: January 2012
Revised: October 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
The terms rhinoplasty, septoplasty and septorhinoplasty are sometimes used interchangeably but they have distinct meanings. A rhinoplasty is a cosmetic or reconstructive procedure that refers to a surgery done to alter the contours of the nose itself without involvement of the underlying nasal septa. A septoplasty on the other hand involves only the septum. However, in clinical practice, a surgical procedure sometimes involves elements of both a rhinoplasty and a septoplasty.
This is referred to as a septorhinoplasty, a more extensive procedure combining repairs to the external nasal pyramid or skeleton with repairs of the nasal septa in order to correct a functional impairment involving both structures. This may involve correcting damage or functional deficits that result from disease, surgery or trauma. The surgery may also be performed to correct a congenital defect such as a cleft lip or palate.
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Prior Approval:
Prior approval is recommended for this service. Submit a prior approval now. 
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Policy:
A rhinoplasty may be considered medically necessary when performed to correct physical functional impairment for ANY of the following:
- Nasal deformity secondary to cleft lip/palate, or
- Significant deformity caused by specifically documented trauma in the last 12 months, or
- Significant deformity after removal of a nasal malignancy, an abscess or osteomyelitis that has caused breathing difficulty, or
- Significant deformity in individuals with documented sleep apnea or breathing difficulty and chronic rhinosinusitis as a result of external nasal pyramid deformity following documented trauma or injury.
Rhinoplasty to repair an external nasal deformity not causing a functional impairment is considered a cosmetic procedure.
A septorhinoplasty may be considered medically necessary when it is performed to correct a symptomatic functional impairment and is not being done primarily for cosmetic purposes.
Documentation submitted for the prior approval process must include all of the following:
- Clinical history of the degree and duration of symptoms related to nasal obstruction or relevant functional impairment and the previous attempts at conventional treatments
- Relevant history of any symptomatic trauma or surgical sequela, congenital defect or disease process
If the documentation submitted for prior approval does not clearly support the medical necessity of the proposed treatment, additional information documenting any symptomatic external deformity may be requested.
Septorhinoplasty performed primarily for cosmetic purposes or in the absence of a clearly documented functional impairment is considered cosmetic.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT** codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 30400 rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
- 30410 complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
- 30420 including major septal repair
- 30430 rhinoplasty, secondary; minor revision (small amount of nasal tip work)
- 30435 intermediate revision (bony work with osteotomies)
- 30450 major revision (nasal tip work and osteotomies)
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Selected References:
- Clinical Practice Parameters and Facility Standards; Plastic Surgery. The College of Physicians and Surgeons of Ontario © 2002.
- Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. American Cleft Palate-Craniofacial Association-Professional Association. 2000 Apr. 30 pages. NGC:003646.
- Diagnosis and treatment of obstructive sleep apnea. Institute for Clinical Systems Improvement, 2003 Apr. (revised 2005 March). 54 pages. NGC:004296.
- Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of obstructive sleep apnea in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Jun. 55 p. NGC:006582
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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