Rhinoplasty and Other Nasal Surgeries Form

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Rhinoplasty and Other Nasal Surgeries - Medical Policy
Updated Revision Effective: October 1, 2025 Policy Number:

UM241POL

Approval Date: 6/24/2025

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Rhinoplasty: A surgical procedure of the nose for reconstructive reasons to improve a nasal deformity, or a damaged nasal structure or to replace lost tissue, while maintaining or improving the physiological function of the nose. It can also be done for cosmetic purposes to correct or improve the external appearance of the nose.

Rhinoplasty for Congenital Defects: A rhinoplasty procedure to address a medical condition present at or from birth that significantly deviates from the common structure or function of the nose or nasal airway; these procedures are most commonly done to treat cleft lip and palate abnormalities, or for removal of a nasal dermoid.

Primary Rhinoplasty: The first rhinoplasty operation performed on a nose

Secondary Rhinoplasty: Any subsequent or revision rhinoplasty surgeries performed on a nose

Rhinoplasty - Tip: A surgical procedure of the tip of the nose to improve nasal function by repairing an existing defect or to enhance the appearance

Nasal Valve Procedures/Repair of Nasal Vestibular Stenosis or Alar Collapse: Surgical procedures to correct nasal valve or vestibule impairment caused by aging, congenital defect, or prior nasal surgery to restore the nasal airway

 Line of Business

Commercial:

• HNE has adopted InterQual* criteria for the following procedures:

o Rhinoplasty: CP:Procedures, Rhinoplasty. • Refer to criteria under the Policy section in this medical policy for Reconstructive Rhinoplasty.

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• Refer to criteria under the Policy section in this medical policy for Revision rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Tip Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Other Nasal Surgeries.

Medicaid – BeHealthy:

• Health New England uses following MassHealth Guidelines for Medical Necessity Determination for Rhinoplasty and Other Nasal Surgeries. https://www.mass.gov/lists/masshealth-guidelines-for-medical- necessity-determination

o Guidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty.

• Refer to criteria under the Policy section in this medical policy for Revision Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Tip Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Other Nasal Surgeries.

Medicare:

• HNE has adopted InterQual* criteria for the following procedures:

o Rhinoplasty: CP:Procedures, Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Reconstructive Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Revision Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Tip Rhinoplasty.

• Refer to criteria under the Policy section in this medical policy for Other Nasal Surgeries.

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Rhinoplasty

A. Health New England has adopted the following InterQual criteria.

o CP:Procedures, Rhinoplasty.

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

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C. Health New England uses MassHealth Guidelines for Medical Necessity Determination for Rhinoplasty and Septoplasty for Medicaid.

D. Rhinoplasty for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY

E. For Procedures performed as part of facial feminization, refer to the Gender Affirming Services medical policy.

II. Reconstructive Rhinoplasty

A. Rhinoplasty for congenital anomalies is considered reconstructive and medically necessary for ANY of the following:

1. Nasal deformity associated with congenital craniofacial anomalies including (but not limited to) Apert Syndrome, Pierre Robin syndrome, Fraser syndrome, Binder syndrome, Goldenhar syndrome, nasal dermoids, Tessier nasal cleft (most commonly no. 1); OR

2. Nasal deformity associated with a cleft lip or cleft palate.

   B. Rhinoplasty can be considered reconstructive for indications under criteria (I).

   III. Revision Rhinoplasty

   A. Revision Rhinoplasty is primarily cosmetic BUT may be considered reconstructive and MEDICALLY NECESSARY when ALL of the following criteria are present:

3. Required as a treatment of a complication or a residual deformity from primary surgery that was performed to address a functional impairment when a documented functional impairment persists due to the complication or a deformity; AND
4. Photos document the secondary deformity or a complication as the primary cause of an anatomic Mechanical Nasal Airway Obstruction and are consistent with the clinical exam; AND
5. The proposed procedure is designed to correct the anatomic Mechanical Nasal Airway Obstruction and relieve the nasal airway obstruction by correcting the deformity or treating the complication; AND
6. Nasal airway obstruction is causing significant symptoms (e.g., Chronic Rhinosinusitis, difficulty breathing); AND

7. Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.

   B. Revision Rhinoplasty for all other indications other than in criteria above is considered COSMETIC, hence NOT MEDICALLY NECESSARY.

   IV. Tip Rhinoplasty

   A. Tip Rhinoplasty is primarily cosmetic BUT it is considered reconstructive and MEDICALLY NECESSARY when ALL of the following criteria are present:

8. Prolonged, Persistent Obstructed nasal breathing due to tip drop that is the primary cause of an anatomic Mechanical Nasal Airway Obstruction; AND
9. Photos document tip drop as the primary cause of an anatomic Mechanical Nasal Airway Obstruction and are consistent with the clinical exam (acute columellar-labial angle); AND

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3. The proposed procedure is designed to correct the anatomic Mechanical Nasal Airway Obstruction and relieve the nasal airway obstruction by lifting the nasal tip; AND
4. Nasal airway obstruction is causing significant symptoms (e.g., Chronic Rhinosinusitis, difficulty breathing); AND

5. Obstructive symptoms persist despite conservative management for 4 weeks or greater, which includes, where appropriate, nasal steroids or immunotherapy.

   B. Revision Rhinoplasty for all other indications other than in criteria above is considered COSMETIC, hence NOT MEDICALLY NECESSARY.

   V. Other Nasal Surgeries (All lines of business)

   A. The insertion of an absorbable lateral nasal implant (e.g., the Spirox Latera Absorbable Nasal Implant, Latera) for the treatment of symptomatic nasal valve collapse (30468) is considered EXPERIMENTAL and INVESTIGATIONAL.

   B. Radiofrequency subcutaneous/submucosal remodeling for the treatment of nasal valve collapse (30469) is considered EXPERIMENTAL and INVESTIGATIONAL.

   C. Radiofrequency ablation (RFA) of the posterior nasal nerve for the treatment of chronic rhinitis (31242) (e.g., RhinAer, ClariFix) is considered EXPERIMENTAL and INVESTIGATIONAL.

   D. Posterior nasal nerve cryoablation for the treatment of chronic rhinitis (31243) is considered EXPERIMENTAL and INVESTIGATIONAL.

   E. Use of blood products (e.g., concentrated growth factor or platelet-rich fibrin) with diced cartilage in rhinoplasty is considered EXPERIMENTAL and INVESTIGATIONAL.

   F. Use of concentrated growth factor extracted from blood plasma for repair of nasal septal mucosal defect following rhinoplasty is considered EXPERIMENTAL and INVESTIGATIONAL.

   Policy Guidelines and Definitions

   Definitions:

   Congenital Defect: A condition that is present at birth

   External Nasal Valve: The caudal septum, along with lower lateral cartilage, alar rim, and nostril sill contribute to the external nasal valve.

   Functional or Physical or Physiological Impairment: A Physical or Functional or Physiological impairment causes deviation from the normal function of a tissue or organ. These result in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

   Mechanical Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) due to a bony or cartilaginous deformity.

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Prolonged, Persistent Nasal Airway Obstruction: Trouble breathing through the nose (not snoring) that has not responded to six weeks of medical management such as nasal steroids, antihistamines, and decongestants

Reconstructive Surgery: Surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function or create a normal appearance to the extent possible

Coding Guidance

Code
Description
PA 30400 Rhinoplasty, primary: lateral and alar cartilages and/or elevation of nasal tip Yes 30410 Rhinoplasty, primary: complete external parts including bony pyramid, lateral and alar cartilages and/or elevation of nasal tip

Yes 30420 Rhinoplasty, primary, including major septal repair Yes 30430 Rhinoplasty, secondary, minor revision (small amount of nasal tip work) Yes 30435 Rhinoplasty, secondary, intermediate revision (bony with osteotomies) Yes 30450 Rhinoplasty, secondary, major revision (nasal tip work with osteotomies)

Yes

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate including columellar lengthening: tip only

Yes 30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate including columellar lengthening: tip, septum, osteotomies Yes 30468 Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) E&I 30469 Repair of nasal valve collapse with low energy, temperature-controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling
E&I

31242 Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve E&I 31243 Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve E&I E&I = Experimental/Investigational

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

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References

Adamson PA, Warner J, Becker D, et al. Revision rhinoplasty: panel discussion, controversies, and techniques. Facial Plast Surg Clin North Am. 2014 Feb;22 (1):57-96.

Ahmad J, Rohrich RJ. The Crooked Nose. Clin Plast Surg. 2016 Jan;43(1):99-113.

American Academy of Otolaryngology − Head and Neck Surgery (AAO-HNS). Position statement: the use of biomaterials in sinonasal procedures. September 2015.

Azizzadeh, B. et al. Master Techniques in Rhinoplasty. 1st ed. Elsevier/Saunders. 2011. Chapter 35, Nasal Airway Obstruction; p. 447-453.

Beck DO, Kenkel JM. Evidence-based medicine: Rhinoplasty. Plast Reconstr Surg. 2014 Dec;134 (6):1356-71.

Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol Clin North Am. 2009 Apr;42 (2):207-25, vii.

Chauhan R, Loewenstein SN, Hassanein AH. Rhinophyma: prevalence, severity, impact and management. Clin Cosmet Investig Dermatol. 2020 Aug 11;13:537-551.

Christophel JJ, Park SS. Complications in rhinoplasty. Facial Plast Surg Clin North Am. 2009 Feb;17 (1):145-56, vii.

Constantian MB. What motivates secondary rhinoplasty? A study of 150 consecutive patients. Plast Reconstr Surg. 2012 Sep;130 (3):667-78.

Corey CL, Most SP. Treatment of nasal obstruction in the posttraumatic nose. Otolaryngol Clin North Am. 2009 Jun;42 (3):567-78.

Daines SM, Orlandi RR. Chronic rhinosinusitis. Facial Plast Surg Clin North Am. 2012 Feb;20 (1):1-10.

Dobratz EJ, Hilger PA. Osteotomies. Clin Plast Surg. 2010 Apr;37 (2):301-11.

Fattahi T, Steinberg B, Fernandes R, et al. Repair of nasal complex fractures and the need for secondary septo- rhinoplasty. J Oral Maxillofac Surg. 2006 Dec;64 (12):1785-9.

Floyd EM, Ho S, Patel P, et al. Systematic review and meta-analysis of studies evaluating functional rhinoplasty outcomes with the NOSE score. Otolaryngol Head Neck Surg. 2017 May;156(5):809-815.

Friedman O, Cekic E, Gunel C. Functional rhinoplasty. Facial Plast Surg Clin North Am. 2017 May;25(2):195-199.

Ghosh A, Friedman O. Surgical Treatment of Nasal Obstruction in Rhinoplasty. Clin Plast Surg. 2016 Jan;43 (1):29-

40. Goiato MC, Dos Santos DM, et al. Solutions for nasal defects. Journal of Craniofacial Surgery 2009;20(6):2238-41. DOI: 10.1097/SCS.0b013e3181bf858c.

    Goudakos JK, Fishman JM, Patel K. A systematic review of the surgical techniques for the treatment of internal nasal valve collapse: where do we stand? Clin Otolaryngol. 2017 Feb;42(1):60-70.

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Gruber RP, Wall Jr SH, Kaufman DL, et al. Plastic Surgery. 3rd ed. Elsevier Inc. 2013. Chapter 21, Secondary rhinoplasty; p. 466-484.

Guyuron, B. Rhinoplasty. 1st ed. Elsevier Inc. 2012. Chapter 1, Surgical Anatomy and Physiology of the Nose; p. 1-26.

Hayes Inc. Evolving Evidence Review. Absorbable nasal implants for the treatment of nasal valve collapse. Lansdale, PA: Hayes, Inc.; March 2021.

Henriquez OA, Schlosser RJ, Mace JC, et al. Impact of synechiae after endoscopic sinus surgery on long-term outcomes in chronic rhinosinusitis. Laryngoscope. 2013 Nov;123(11):2615-9.

Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002 Mar;109 (3):1128-46.

International Forum Allergy and Rhinology. Volume 3. January 2013.

Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty executive summary. Otolaryngol Head Neck Surg. 2017 Feb;156(2):205-219.

Jafek B.W., Dodson B.T., et al: Nasal obstruction. In Bailey B.J., (eds): Head and neck surgery − otolaryngology, 5th edition. Philadelphia: Lippincott-Raven,2013. pp. 371-377.

Lazovic GD, Daniel RK, Janosevic LB, et al. Rhinoplasty: the nasal bones − anatomy and analysis. Aesthet Surg J. 2015 Mar;35 (3):255-63.

Martin MM, Hauck K, von Witzleben A, et al. Treatment success after rhinosurgery: an evaluation of subjective and objective parameters. Eur Arch Otorhinolaryngol. 2022 Jan;279(1):205-211.

Pfaff MJ, Bertrand AA, Lipman KJ, et al. The effect of functional nasal surgery on olfactory function. Plast Reconstr Surg. 2021 Mar 1;147(3):707-718.

Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010 Jul;143(1):48-59.

Rohrich, Rod J. et al. Plastic Surgery: Indication and Practice. 1st ed. CRC Press. 2009. Chapter 113, Primary Rhinoplasty; p. 1479-1508.

Silvers SL, Rosenthal JN, McDuffie CM, et al. Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: a randomized controlled trial. Int Forum Allergy Rhinol. 2021 Dec;11(12):1676-1684.

Smith TL, Kern RC, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi- institutional study. Int Forum Allergy Rhinol. 2011; 1:235-241.

Spielmann PM, White PS, Hussain SS. Surgical techniques for the treatment of nasal valve collapse: a systematic review. Laryngoscope. 2009 Jul;119(7):1281-90.

Tanna N, Nguyen K, Ashkan G, et al. Evidence-based medicine: Current practices in rhinoplasty. PRSJournal.com. 2017Aug;PRS.0000000000003977:137-151.

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Zhao R, Chen K, Tang Y. Effects of functional rhinoplasty on nasal obstruction: a meta-analysis. Aesthetic Plast Surg. 2022 Jan 31.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 12/2003 Initial Policy Date 03/2022 No significant change 04/2023 Policy title changed to be inclusive of other nasal surgical procedures and some criteria and codes updates. 1/2024 Line of Business section added

06/2024 Minor criteria and code updates. MassHealth guidelines added for Medicaid. Added CPT codes 31242 and 31243 as experimental/investigational 06/2025 Added criteria for Reconstructive Rhinoplasty. Added criteria for Revision rhinoplasty. Added criteria for Tip Rhinoplasty.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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). Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. 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. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.