Prior authorization request form Form

Septoplasty

Last Review Date: January 23, 2026  
Number: MG.MM.SU.04gC3

Medical Guideline Disclaimer The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
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Definition Septoplasty (submucosal resection of the septum) is the surgical correction or reconstruction of the nasal septum, which divides the right and left cavities. The septum is generally situated in the direct center of the nose; however, when the septum is off-center or misaligned, corrective surgery is sometimes required to correct the breathing impairment that results from the misalignment. Related Guidelines Cosmetic Surgery and Reconstructive Procedures Rhinoplasty Guideline Members are eligible for coverage of septoplasty when at least 1 of the following conditions exists: I. Reconstruction post tumor or polyp removal or surgical excision of part of the ethmoid bone (ethmoidectomy or turbinate reduction).
II. Chronic nasal obstruction attributable to deviated septum that results in significant medical disabilities, such as:

1. Recurrent purulent sinusitis1 (> 3 episodes per year) with clinically significant obstruction. Conservative management has failed to alleviate or prevent episodes of sinusitis, including all:  Antibiotics  Antihistamines, decongestants, nasal sprays or topical steroids  Attempts to discontinue nasal irritants such as smoking, drugs and inadequate humidification
2. Nasal septal deformity or spur (congenital or acquired) with clinically significant obstruction; all:
    Assessment and testing, if appropriate, for allergic conditions completed  Conservative management failure in the presence of allergic rhinitis (i.e., allergic precautions, antihistamines, topical nasal steroids and plus/minus desensitization injections)  General conservative management failure (i.e., reduction of all nasal irritants such as smoking, occupational exposures, drugs and inadequate humidification)
3. Recurrent Epistaxis (at least 4, or an episode of severe epistaxis associated with a septal deviation or spur seen on exam); both:  Conservative treatment measure failure, such as avoidance of medications affecting coagulation, addition of environmental humidity and cauterization  Nasal spur or septal deformity etiology of abnormal airflow
4. Unusual facial pain originating from the nasal area and relieved by septal anesthesia.

5. Impending septal perforation (hole through the septum); both:
    Significant septal deviation with airflow obstruction  Conservative measure failure, including humidification, desisting further digital trauma, reduction of nasal irritants (smoking, drugs) and drug therapy (decongestants, antihistamines, nasal steroids), if indicated III. Asymptomatic deformity that prevents surgical access to other intranasal or paranasal areas (e.g., sinuses, turbinates) IV. When performed in association with cleft palate repair V. Obstructive sleep apnea. (to aid in ability to utilize CPAP and help upper airway obstruction) (Eff. 2/12/2022) (Note: for those members with allergic rhinitis who also have OSA, documentation of conservative management failure in the presence of allergic rhinitis [i.e., allergic precautions, antihistamines, topical nasal steroids and plus/minus desensitization injections] should be submitted) Limitations/Exclusions Septoplasty is not considered medically necessary for any indications other than those listed above. Absorbable nasal implants for the treatment of nasal valve collapse (e.g., Latera® Absorbable Nasal Implant, CPT 30468) are considered investigational for Commercial and Medicaid.

   1 Diagnosis must be documented by both of the following: Symptoms (including purulent nasal drainage) and radiologic evidence of either recurrent acute sinusitis (> 3 episodes per year) or chronic rhinosinusitis (symptoms > 12 weeks (clouding of sinuses, thickening of sinus membranes on limited CT).

Applicable Procedure Codes 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) Applicable Diagnosis Codes C30.0 Malignant neoplasm of nasal cavity C31.0 Malignant neoplasm of maxillary sinus C31.1 Malignant neoplasm of ethmoidal sinus C31.2 Malignant neoplasm of frontal sinus C31.3 Malignant neoplasm of sphenoid sinus C31.8 Malignant neoplasm of overlapping sites of accessory sinuses C41.0 Malignant neoplasm of bones of skull and face C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D16.4 Benign neoplasm of bones of skull and face G47.30 Sleep apnea, unspecified G47.31 Primary central sleep apnea G47.32 High altitude periodic breathing G47.33 Obstructive sleep apnea (adult) (pediatric) J32.0 Chronic maxillary sinusitis J32.1 Chronic frontal sinusitis J32.2 Chronic ethmoidal sinusitis J32.3 Chronic sphenoidal sinusitis J32.4 Chronic pansinusitis J32.8 Other chronic sinusitis J32.9 Chronic sinusitis, unspecified J33.0 Polyp of nasal cavity J33.1 Polypoid sinus degeneration J33.8 Other polyp of sinus J33.9 Nasal polyp, unspecified J34.0 Abscess, furuncle and carbuncle of nose J34.1 CYST and mucocele of nose and nasal sinus J34.2 Deviated nasal septum J34.89 Other specified disorders of the nose and paranasal sinuses M95.0 Acquired deformity of nose Q30.3 Congenital perforated nasal septum Q30.8 Other congenital malformations of the nose

R04.0 Epistaxis R09.81 Nasal congestion

References Dinis PB, Haider H. Septoplasty: long-term evaluation of results. Am J Otolaryngol. 2002;23:85-90. Doyle RL. Healthcare Management Guidelines. Vol 1. 2nd ed. Seattle: Milliman and Robertson; 1997. Godley FA, Nemeroff RF, Josephson JS. Current trends in rhinoplasty and the nasal airway. Med Clin North Am. 1993;77:643-656. Grossman ZD, Katz DS, Santelli ED, et al. Sinusitis. In: Cost-Effective Diagnostic Imaging: The Clinician’s Guide. 3rd ed. St. Louis: Mosby; 1995:376-377. Huerter JV. Functional endoscopic sinus surgery and allergy. Otolaryngol Clin North Am. 1992;25:231-238.
Lund VJ. Office evaluation of nasal obstruction. Otolaryngol Clin North Am. 1992;25:803-815.
Marshall, KG, Elhamy LA. Disorders of the Nose and Paranasal Sinuses. Littleton, Mass: PSG Publishing Co.; 1987.
Schuller DE, Schleuning AJ. DeWeese and Saunders’ Otolaryngology: Head and Neck Surgery. 8th ed. St. Louis: Mosby; 1994.
Specialty-matched clinical peer review.
Revision History
Company(ies)

  DATE

REVISION EmblemHealth Feb. 14, 2025 Transferred policy content to individual company branded template ConnectiCare EmblemHealth Jan. 19, 2023 Added documentation note pertaining to obstructive sleep apnea indication ConnectiCare EmblemHealth Nov. 12, 2021 Added obstructive sleep apnea (to aid in ability to utilize CPAP and help upper airway obstruction) as a covered indication (eff. 2/12/2022) ConnectiCare Jun. 1, 2021 Added investigational language for absorbable nasal implants to Limitations/Exclusions section. EmblemHealth Sept. 14, 2018 Substituted language pertaining to “50 percent obstruction” for sinusitis and nasal deformity with “clinically significant obstruction”. EmblemHealth Aug. 12, 2016 Added septoplasty coverage when performed with cleft palate repair, as well as when an asymptomatic deformity impacts surgical access to other intranasal/paranasal areas.