Medical Policy
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

 
Limits
Intentially left empty
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.