Rhinoplasty or Septorhinoplasty*

Medical Policy: 07.01.29
Original Effective Date: October 2005
Reviewed: March 2008
Revised: January 2007

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.

Policy:

Prior approval is recommended for this service. Submit a prior approval now

A rhinoplasty or septorhinoplasty may be considered medically necessary and a covered benefit 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.

Any rhinoplasty or septorhinoplasty performed primarily for cosmetic purposes or in the absence of a clearly documented functional impairment is considered cosmetic and is not a covered benefit.

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Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
CPT code 30400 rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
CPT code 30410 complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
CPT code 30420 including major septal repair
CPT code 30430 rhinoplasty, secondary; minor revision (small amount of nasal tip work)
CPT code 30435 intermediate revision (bony work with osteotomies)
CPT code 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.

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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Prior Approval is recommended for this policy.

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.