Septoplasty and Rhinoplasty Form

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Septoplasty and Rhinoplasty Medical Guideline

Service: Septoplasty and Rhinoplasty

PUM 250-0028-1812

Medical Guideline Committee Approval Q4-2025 Effective Date 03/01/2026

Coverage for Septoplasty and rhinoplasty may vary across plans. Refer to the member’s benefit plan document for coverage details.

Definitions:

Reconstructive surgery, for the purpose of this guideline, is when the primary purpose of the surgery is to correct functional impairment caused by an illness, injury, congenital abnormality, acute traumatic injury, tumors, or cancer.

Cosmetic treatment, for the purpose of this guideline, is any health care service used solely to: (1) change or improve physical appearance or self-esteem; or (2) treatment of a condition that causes no functional impairment or threat to health.

Cosmetic procedures are not typically a covered benefit of health plans.
Procedures/services that correct a congenital abnormality without improving or restoring a functional deficit are considered cosmetic treatment and not medically necessary.

Description:

Septoplasty is a surgical procedure performed on the internal anatomy of the nose to improve obstructed breathing or due to tumors or epistaxis.

Rhinoplasty is a surgical procedure performed to correct nasal fractures or breathing difficulties. It is also often performed for cosmetic purposes to change the shape or size of the nose to enhance appearance.

Septoplasty and rhinoplasty may sometimes be performed as a combined surgical repair (rhino septoplasty) of the external nasal pyramid and the nasal septum to correct a functional impairment caused by both.

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Indications of Coverage:

A. Nasal septoplasty is considered medically necessary when any one of the following is met:

1. Septoplasty is performed to correct functional impairment of the nose in association with repair of congenital facial anomaly (e.g., cleft palate, congenital pyriform aperture stenosis [CPAS], choanal atresia or nasal destruction with granulomatosis with polyangiitis), or a traumatic deformity that would not respond to medical therapy alone.

2. The individual has a deviated septum, septal spurring, or a septal deformity causing at least moderate to severe nasal fossa narrowing seen on physical exam, endoscopy, or imaging despite 4 weeks of appropriate medical treatment (e.g., nasal corticosteroids, antihistamines, antibiotics) and at least one of the following:

   a. Recurrent nosebleeds (at least 4 in the most recent two months) related to deformity of septum.

   b. Recurrent sinusitis and/or recurrent nasal congestion felt by healthcare practitioner to be due to deviated septum, septal spurring, or a septal deformity that is not responsive to at least 4 weeks of appropriate medical treatment (e.g., nasal corticosteroids, antihistamines, antibiotic)

   c. Septal deformity prevents performance of medically necessary surgical procedure during which access to intranasal areas is necessary (such as access for ethmoidectomy)

   d. Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management (e.g., nasal corticosteroids, antihistamines, antibiotics) lasting at least six weeks and is interfering with the use of medically necessary continuous positive airway pressure (CPAP) for the treatment of an obstructed sleep disorder with an apnea/hypopnea index [AHI] ≥ 15 as documented by polysomnography or home sleep study.

   B. Rhinoplasty is considered medically necessary when one of the following is met:

3. The condition cannot be corrected with septoplasty and/or turbinectomy and a rhinoplasty is needed for one of the following:

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a. To correct functional impairment of the nose in association with repair of congenital craniofacial anomaly (e.g., cleft palate, congenital pyriform aperture stenosis [CPAS], choanal atresia or nasal destruction with granulomatosis with polyangiitis), or a traumatic deformity that would not respond to medical therapy alone.

b. To correct functional impairment associated with deformity of the nasal pyramid. There must be documented chronic, obstructed nasal breathing that is unresponsive to at least 4 weeks of conservative management (such as intranasal steroids/antihistamines, nasal lavage, oral steroids), with physical exam documenting at least a moderate degree of nasal vestibular obstruction and nasal endoscopy or imaging showing at least moderate degree of obstruction of one, or both nares. Medical records should address why a septoplasty and/or turbinectomy will not correct the obstruction.

c. Nasal obstruction secondary to nasal valve collapse, as indicated by ALL of the following:

• Clinical findings of collapsed internal nasal valve at rest or collapsed external nasal valve (lateral walls) with inspiration. • Infection, allergy, rhinitis, and polyps eliminated as primary cause of nasal obstruction. • Patient has received appropriate medical treatment for symptoms, with intranasal antihistamine and intranasal steroids.
• Symptoms of nasal obstruction (e.g., snoring, mouth breathing) affect quality of life.

d. To prevent nasal valve narrowing or collapse following the excision of a large cutaneous malignancy or nasal tumor.

NOTE: If rhinoplasty is being performed with a medically necessary septoplasty, medical records must document why both procedures are indicated.

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

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A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Nasal valve suspension for the repair of nasal valve collapse will be considered experimental, investigational, and unproven to affect health outcomes.

E. Absorbable nasal implant or implants to support the nasal cartilages (e.g., Latera® Absorbable Nasal Implant [Stryker]) will be considered experimental, investigational, and unproven to affect health outcomes.

F. Radiofrequency energy (e.g., Vivaer® nasal airway remodeling) to remodel nasal airway will be considered experimental, investigational, and unproven to affect health outcomes.

G. Nasal cryotherapy (e.g., Clarifix®, RhinAer) will be considered experimental, investigational, and unproven to affect health outcomes.

H. Rhinoplasty for the treatment of obstructive sleep apnea will be considered experimental, investigational, and unproven to affect health outcomes.

I. Septoplasty or rhinoplasty for the treatment of allergic rhinitis will be considered experimental, investigational, and unproven to affect health outcomes.

J. Rhinoplasty to alter the shape or size of the nose to enhance appearance will be considered cosmetic and not medically necessary.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
• Medical record information (including continued need/use if applicable) and medical necessity. Office visit notes, Imaging/diagnostic reports
• Correct coding for the item/service that meets all the coding guidelines.

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Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Septoplasty and Rhinoplasty procedures are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

Guideline Review History:

Implemented 01/01/20, 12/01/20, 08/01/21, 08/01/22, 08/01/23, 08/01/24, 03/01/26 Medical Guideline Committee Approval 08/30/19, 08/20/20, 07/29/21, 07/28/22, 07/27/23, 07/25/24, Q4 2025 Reviewed

08/20/20, 07/29/21, 07/28/22, 07/27/23, 07/25/24, Q4 2025 Developed 08/30/19

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 30150 RHINECTOMY; PARTIAL 30160 RHINECTOMY; TOTAL 30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP

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30410 RHINOPLASTY, PRIMARY, COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR 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 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 (E.G., SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION) 30468 REPAIR OF NASAL VALVE COLLAPSE WITH SUBCUTANEOUS/SUBMUCOSAL LATERAL WALL IMPLANT(S)
30469 REPAIR OF NASAL VALVE COLLAPSE WITH LOW ENERGY, TEMPERATURE-CONTROLLED (IE, RADIOFREQUENCY) SUBCUTANEOUS/SUBMUCOSAL REMODELING 30520 SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT 30620 SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT INCLUDE OBTAINING GRAFT)