Prior authorization request form Form

Rhinoplasty

Last Review Date: September 12, 2025 Number: MG.MM.SU.08iC4

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.
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Definitions Rhinoplasty is a surgical procedure of the nose to correct external nasal deformity while maintaining, restoring or improving nasal function.

Related Medical Guidelines Cosmetic and Reconstructive Surgery Procedures
Septoplasty Guideline Members are eligible for rhinoplasty when either of the following criteria is met:

1. Performed in conjunction with a septoplasty for nasal airway obstruction when the nasal deformity contributes to the airway obstruction and septoplasty criteria are met.
2. Performed as part of reconstruction for severe deformity when documented obstructive breathing symptoms secondary to any of the following are present: • Excision of a nasal abscess. • Excision of a malignant mass. • Osteomyelitis. • Cleft lip and/or palate repair. • Nasal trauma or injury that resulted in significant deviation of the nasal pyramid or a

creation of a significant dorsal hump.
• Nasal dermoid • Saddle nose deformity from surgery, trauma, or disease (Granulomatosis with Polyangiitis). • Vestibular stenosis for prolonged nasal obstruction which is moderate to severe, separate from obstruction caused by deviated septum or turbinate hypertrophy, and causing problems such as breathing difficulty, bleeding, or sinusitis Limitations/Exclusions Rhinoplasty is not covered when any of the following are applicable:

1. Performed solely to change appearance in the absence of any signs or symptoms of functional abnormalities or nasal defects, as this would be considered cosmetic.
2. For treatment of polyps not causing severe deformity.

3. 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.

   Revision History Feb. 10, 2023 Removed photo documentation prerequisite Sept.10, 2021 Eliminated prerequisite for nasal trauma/injury to have occurred within 18-months of surgical request
   Removed prerequisite for documentation at time of trauma
   Removed "from a large septal perforation" as an etiology descriptive pertaining to saddle nose deformity
   Jun. 1, 2021 Added investigational language for absorbable nasal implants to Limitations/Exclusions section. Mar. 13, 2020 Added nasal dermoid, saddle nose deformity and vestibular stenosis as covered indications. Applicable Procedure Codes

   30124 Excision dermoid cyst, nose; simple, skin, subcutaneous 30125 Excision dermoid cyst, nose; complex, under bone or cartilage 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) 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)

Applicable ICD-10 Diagnosis Codes C11.3
Malignant neoplasm of anterior wall of nasopharynx
C30.0
Malignant neoplasm of nasal cavity
C43.31
Malignant melanoma of nose
C44.311 Basal cell carcinoma of skin of nose C44.321 Squamous cell carcinoma of skin of nose C44.391 Other specified malignant neoplasm of skin of nose D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D38.5 Neoplasm of uncertain behavior of other respiratory organs D49.1 Neoplasm of unspecified behavior of respiratory system J34.0
Abscess, furuncle and carbuncle of nose
J34.1
Cyst and mucocele of nose and nasal sinus
J34.89
Other specified disorders of nose and nasal sinuses
J34.9
Unspecified disorder of nose and nasal sinuses
M86.68
Other chronic osteomyelitis, other site
M86.8X8
Other osteomyelitis, other site
M95.0
Acquired deformity of nose
Q30.1 Agenesis and underdevelopment of nose Q30.2 Fissured, notched and cleft nose Q30.3 Congenital perforated nasal septum Q30.8 Other congenital malformations of nose Q35.1
Cleft hard palate
Q35.3
Cleft soft palate
Q35.5
Cleft hard palate with cleft soft palate
Q35.9
Cleft palate, unspecified
Q36.0
Cleft lip, bilateral
Q36.1
Cleft lip, median
Q36.9
Cleft lip, unilateral
Q37.0
Cleft hard palate with bilateral cleft lip
Q37.1
Cleft hard palate with unilateral cleft lip
Q37.2
Cleft soft palate with bilateral cleft lip
Q37.3
Cleft soft palate with unilateral cleft lip
Q37.4
Cleft hard and soft palate with bilateral cleft lip
Q37.5
Cleft hard and soft palate with unilateral cleft lip
Q37.8
Unspecified cleft palate with bilateral cleft lip
Q37.9
Unspecified cleft palate with unilateral cleft lip
S00.30XA Unspecified superficial injury of nose, initial encounter
S01.20XA Unspecified open wound of nose, initial encounter
S01.21XA Laceration without foreign body of nose, initial encounter S01.22XA Laceration with foreign body of nose, initial encounter S01.23XA Puncture wound without foreign body of nose, initial encounter S01.24XA Puncture wound with foreign body of nose, initial encounter S01.25XA Open bite of nose, initial encounter
S02.2XXA Fracture of nasal bones, initial encounter for closed fracture
S02.2XXB Fracture of nasal bones, initial encounter for open fracture
S07.0XXA Crushing injury of face, initial encounter
S08.811A Complete traumatic amputation of nose, initial encounter
S08.812A Partial traumatic amputation of nose, initial encounter

References Cummings-Otolaryngology Head and Neck Surgery April 2021. AAO HNS Clinical Indicators. https://www.entnet.org/resource/clinical-indicators-adenoidectomy/. Accessed October 20, 2025.

Specialty-matched clinical peer review.