Humana Rhinoplasty-Septoplasty Form

Description

Reconstructive rhinoplasty is surgery of the nose to correct an external nasal deformity, damaged nasal structures or to replace lost tissue, while maintaining or improving the physiological function of the nose.

Reconstructive septoplasty is the surgical correction of defects and deformities of the nasal septum (partition between the nostrils) by altering, splinting or removing obstructive tissue while maintaining or improving the physiological function of the nose.

Cosmetic rhinoplasty and/or septoplasty are performed solely to enhance appearance.

Rhinoplasty/Septoplasty Effective Date: 05/25/2023

Revision Date: 05/25/2023

Review Date: 05/25/2023

Policy Number: HUM-0315-022

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Balloon septoplasty, involving the insertion and inflation of a balloon catheter into the nose, has been proposed as treatment for septal deviation. (Refer to Coverage Limitations Section)

Nasal Valves

The nasal valves or vestibules are the areas just inside the nostrils comprised of cartilage and structured to work together to keep the nasal airway open by facilitating airflow resistance during breathing. The internal valves are located in each side of the nose at the upper edge of the hair bearing area, while the outer (external) valves are at the edge of the nostril rim. Aging, congenital abnormality or prior nasal surgery may cause valve impairment (eg, nasal valve collapse, vestibular stenosis). Nasal valves may narrow, weaken or collapse resulting in symptoms of nasal obstruction.

Traditional surgical methods for nasal valve repair depend upon the location and extent of the structural and functional impairment, but generally may include rhinoplasty, septoplasty, turbinoplasty, spreader grafts and batten grafts. Spreader grafts are formed from autologous cartilage and act as wedges between the septum and the upper lateral cartilage, thereby enlarging the internal valve. Batten grafts, constructed from autologous cartilage (eg, septum, ear, rib) are used to provide structure to the nasal side wall, supporting a weakened or pinched external valve.

Nasal valve suspension surgery involves inserting a suture through the nasal mucosa, into the nasal valve and using a bone anchor to secure the suture to the orbital rim, purportedly maintaining valve patency. The procedure has been proposed as a treatment for nasal valve collapse. (Refer to Coverage Limitations Section)

Absorbable nasal implants (Latera) have also been proposed for treating nasal valve collapse. The implant is intended to support upper and lower lateral nasal cartilage and is inserted during a minimally invasive surgical procedure. The implant purportedly absorbs over approximately 18 months. (Refer to Coverage Limitations Section)

Low-power temperature-controlled radiofrequency energy is being studied for use in treating nasal obstruction caused by weakened or collapsed nasal valves. An example of a US Food & Drug Administration (FDA)-approved device, the Vivaer

Rhinoplasty/Septoplasty Effective Date: 05/25/2023

Revision Date: 05/25/2023

Review Date: 05/25/2023

Policy Number: HUM-0315-022

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The remodeling platform, delivers nonablative radiofrequency energy via a stylus inserted into the nostril, which purportedly shrinks submucosal nasal tissues, including cartilage that may be obstructing the nasal airway. (Refer to Coverage Limitations Section)

For information regarding treatment for turbinate hypertrophy or septoplasty for obstructive sleep apnea, please refer to Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Surgical Treatments Medical Coverage Policy.

For information regarding treatments for rhinosinusitis and Eustachian tube dysfunction, please refer to Balloon Dilation (Eustachian Tube and Sinus), Functional Endoscopic Sinus Surgery and RhinAer Medical Coverage Policy.

Coverage Determination

Any state mandates for rhinoplasty or septoplasty relating to gender affirmation surgery take precedence over this medical coverage policy.

Rhinoplasty

Humana members may be eligible under the Plan for rhinoplasty for the following indications:

• Correction of a constant or intermittent nasal airway obstruction occurring as a result of an internal or external nasal deformity, including nasal valve collapse or vestibular stenosis AND obstructive symptoms are supported by EITHER of the following:
  1. Constant or intermittent clinically significant* nasal airway obstruction in an individual with allergy signs/symptoms, despite an 8 week trial of nasal steroids or a minimum of 3 months of immunotherapy; OR
  2. Nasal obstruction documented by imaging or clinical examination and nasal endoscopy, with evidence of treated medical complications, such as 3 or more episodes of acute nasal/sinus infections in the past 12 months or at least one chronic infection (12 weeks or more despite treatment); OR

Rhinoplasty/Septoplasty Effective Date: 05/25/2023

Revision Date: 05/25/2023

Review Date: 05/25/2023

Policy Number: HUM-0315-022 Page: 4 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Correction of a functional impairment** of the nose caused by acute trauma (less than or equal to 3 months prior); OR
• Correction of a functional impairment** of the nose due to congenital defects (eg, congenital pyriform aperture stenosis [CPAS], choanal atresia, cleft lip and/or palate)

Septoplasty

Humana members may be eligible under the Plan for septoplasty for the following indications:

• Atypical face pain of nasal origin when there is documentation of septal cause (eg, presence of septal spur impacting on the turbinates); OR
• Clinically significant* obstruction due to trauma which is more than 3 months old; OR
• Correction of a constant or intermittent nasal airway obstruction occurring as a result of an internal or external nasal deformity, including nasal valve collapse or vestibular stenosis AND obstructive symptoms are supported by EITHER of the following:
  1. Constant or intermittent clinically significant* nasal airway obstruction in an individual with allergy signs/symptoms, despite an 8 week trial of nasal steroids or a minimum of 3 months of immunotherapy; OR
  2. Nasal obstruction documented by imaging or clinical examination and nasal endoscopy, with evidence of treated medical complications, such as 3 or more episodes of acute nasal/sinus infections in the past 12 months or at least one chronic infection (12 weeks or more despite treatment); OR
• Correction of a functional impairment** of the nose caused by acute trauma (less than or equal to three months prior); OR

Rhinoplasty/Septoplasty Effective Date: 05/25/2023 Revision Date: 05/25/2023 Review Date: 05/25/2023 Policy Number: HUM-0315-022 Page: 5 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Correction of a functional impairment** of the nose due to congenital defects (eg, congenital pyriform aperture stenosis [CPAS], choanal atresia, cleft lip and/or palate); OR
• Deformity that prevents surgical access to other intranasal areas (eg, deviated septum, polyps or tumor); OR
• If necessary in conjunction with nasal polypectomy or tumor removal; OR
• Nasal septal perforation; OR
• Sinus endoscopy or ethmoidectomy, when there is clinically significant* obstruction and history/physical examination or imaging documenting sinus disease; OR
• Treatment of a problem that has caused recurrent and significant epistaxis (4 or more episodes in the last 2 months or receipt of blood transfusion)*

*Clinically significant is defined as:

• More than one consultation with an otolaryngologist for the problem; AND
• Documentation with results of the follow-up from the otolaryngologist or another provider for the problem; AND at least one of the following:
  • Heavy snoring; OR
  • Mouth breathing; OR
  • Recurrent sinus infections; OR
  • Serious adverse effects to mucosal control medications or the use of medication is contraindicated (eg, would not alleviate the obstruction due to anatomy)

** Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part.

Rhinoplasty/Septoplasty Effective Date: 05/25/2023 Revision Date: 05/25/2023 Review Date: 05/25/2023 Policy Number: HUM-0315-022 Page: 6 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Limitations

Humana members may NOT be eligible under the Plan for rhinoplasty and/or septoplasty for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for balloon septoplasty for septal deviation. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the repair of nasal valve collapse using the following treatments:

• Absorbable nasal implants (Latera); OR
• Nasal valve suspension surgery; OR
• Radiofrequency energy (Vivaer)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about congenital defects of the nasal cavity, nasal polyps, nasal septal defects or nasal valve impairment may be found from the following websites:

Background

• American Academy of Otolaryngology-Head and Neck Surgery
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Rhinoplasty/Septoplasty Effective Date: 05/25/2023 Revision Date: 05/25/2023 Review Date: 05/25/2023 Policy Number: HUM-0315-022 Page: 7 of 10

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.