Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:

Effective Date: 11/01/2003

Title: Rhinoplasty

Revision Date: 04/01/2018

Document: BI147:00

CPT Code(s): 30400; 30420; 30430-30450; 30465; 30520; C9749

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Rhinoplasty is a surgical procedure to reshape the contour and shape of the nose. When rhinoplasty is performed primarily to change the appearance of the nose, it is considered cosmetic, and is not covered. See the Cosmetic Surgery policy.

Septoplasty is a procedure to move or realign a deviated nasal septum to help to clear the breathing in one nostril that is blocked. This procedure is covered.

When both Rhinoplasty and Septoplasty are performed together, QualChoice will require an operation report and other medical records, which will be reviewed to determine the medical necessity of the procedure.

Medical Statement

Cosmetic surgery is defined by this plan as being surgery performed primarily to improve appearance or for the psychological benefit of the patient. Rhinoplasty performed solely to change the appearance of the nose fits into this definition, and is excluded as cosmetic in nature.

Procedures performed to improve the function of the nose are generally covered. This would include procedures to open up blocked nasal passages and procedures to achieve proper drainage of the paranasal sinuses. Such procedures would be considered medically necessary and paid.

Procedures to correct nasal vestibular stenosis (30465, C9749) require prior authorization (online automated process) to document medical necessity.

When there is question about the intended effect of a procedure, QualChoice reserves the right to:

Request and review the operative report and any other pertinent medical records.
Request and review any and all clinical evaluations leading up to the surgery.
Deny coverage retrospectively and recoup payments to all participants if it is found, based on review, that the surgery was cosmetic in nature.
Authorize coverage retrospectively or prospectively based on review.

Codes Used In This BI:

C9749	Repair nasal vest lateral wall stenosis with implant
30400	Reconstruction of nose
30410	Reconstruction of nose
30420	Reconstruction of nose
30430	Revision of nose
30435	Revision of nose
30465	Repair nasal vest lateral wall stenosis
30450	Revision of nose
30520	Repair of nasal septum

Reference

Addendum:

Effective 01/01/2017: Code updates

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.