Rhinoplasty

Description of Procedure or Service

Rhinoplasty is an operation on the nose to correct nasal contour and/or to restore nasal function. Although it is typically performed for cosmetic purposes to correct or improve the external appearance of the nose, there may be situations when it may be considered reconstructive in nature. Nasal deformities may be congenital, (e.g., cleft lip and/or cleft palate) or acquired (e.g., trauma, disease, ablative surgery).

Vestibular stenosis or collapse of the internal valves may be a cause of nasal obstruction. The nasal valve refers to tissue that acts as a bridge between the bony skeleton and the nasal tip and can account for approximately half of the total airway resistance of the entire upper and lower respiratory tract. Nasal valve compromise may account for nasal airway obstruction. The causes of internal nasal valve obstruction may include: previous surgery, trauma, facial paralysis, aging, and cleft lip nasal deformities.

Related Policy
Cosmetic and Reconstructive Surgery

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for rhinoplasty when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. BCBSNC will not provide coverage if the procedure is for cosmetic purposes.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Rhinoplasty is covered

Rhinoplasty may be considered medically necessary in the following conditions:

1. For deformities of the bony nasal pyramid (nasal bones and nasal process of the maxilla) that: 
   • directly cause significant and symptomatic airway compromise, sleep apnea or recurrent or chronic rhinosinusitis, and
   • are not responsive to appropriate medical management. 
2. For reconstruction following removal of nasal malignancy, destructive inflammatory diseases (e.g., Granulomatosis with polyangiitis [GPA], pleomorphic granulomatosis), abscess or osteomyelitis that has caused severe deformity and breathing difficulty, or 
3. For deformity of the bony nasal pyramid caused by specifically documented trauma, or 
4. For trauma-related nasal airway obstruction leading to chronic rhinosinusitis NOT RESPONDING TO MEDICAL THERAPY, regardless of date of injury.

When Rhinoplasty is not covered

For change in the external appearance of the nose in the absence of trauma or injury. This is considered cosmetic. 

Policy Guidelines

Clinical nasal examination should include rhinoscopy, or endoscopy if clinically indicated, after mucosal decongestion, with description of nasal bony pyramid, septum and turbinates.

Rhinosinusitis may be classified by duration as acute (less than 4 weeks) or chronic (more than 12 weeks, with or without acute exacerbations).

When there are 4 or more acute episodes per year, without persistent symptoms between episodes, the condition is termed recurrent rhinosinusitis.

Rhinoplasty may require prior plan approval.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465

If documentation is requested, the following documentation should be supplied:

• Pre-operative photos must be submitted consisting at a minimum of legible frontal, lateral, and base views; 
• Complete medical records including patient history, documentation of sleep apnea and other symptoms of breathing obstruction (i.e., nasal stuffiness, dryness, mouth breathing, etc.), including conservative treatment; 
• If result of trauma or injury, include medical records documenting history of trauma or injury with date of injury and any other related surgeries.

Scientific Background and Reference Sources

BCBSNC Claims Policy Manual CMS 60-1A

Consultant Review - 4/96

Medical Director and Physician Advisory Group - 2/97

Reaffirmed - 5/99

Medical Policy Advisory Group - 8/99

Specialty Matched Consultant Advisory Panel - 7/2000

Medical Policy Advisory Group - 9/14/2000

Specialty Matched Consultant Advisory Panel - 6/2002

Specialty Matched Consultant Advisory Panel - 6/2004

Specialty Matched Consultant Advisory Panel - 6/1/06

Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. (September 2007) Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg, 2007 Sep; 137(3 Suppl):S1-31. Retrieved March 5, 2008

Specialty Matched Consultant Advisory Panel - 6/23/08

Specialty Matched Consultant Advisory Panel - 8/2012

American Academy of Otolaryngology – Head and Neck Surgery Clinical Indicators: Rhinoplasty. Retrieved June 22, 2012

Specialty Matched Consultant Advisory Panel - 8/2013

Specialty Matched Consultant Advisory Panel - 9/2014

Specialty Matched Consultant Advisory Panel - 8/2015

Dutton JM. Rhinoplasty (Functional). American Rhinologic Society. February 2015. Last accessed 6/22/2016.

Specialty Matched Consultant Advisory Panel - 8/2016

Ishii LE, Tollefson TT, Basura GJ,et.al. Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty. American Academy of Otolaryngology-Head and Neck Surgery, 2017; 156 (2_suppl): S1

Specialty Matched Consultant Advisory Panel - 8/2017

Specialty Matched Consultant Advisory Panel - 8/2018

Specialty Matched Consultant Advisory Panel - 8/2019

Specialty Matched Consultant Advisory Panel - 8/2020

Specialty Matched Consultant Advisory Panel - 8/2021

Specialty Matched Consultant Advisory Panel - 8/2022

Medical Director Review - 8/2023

Specialty Matched Consultant Advisory Panel - 8/2023

Medical Director Review - 8/2024 

Specialty Matched Consultant Advisory Panel – 8/2024

Policy Implementation/Update Information

6/97 Original Policy issued.

5/99 Reaffirmed. 

6/99 Reformatted, Description of Procedure or Service changed, Medical Term Definitions added.

8/99 Medical Policy Advisory Group

7/00 Specialty Matched Consultant Advisory Panel. Criteria statement changed in “When Rhinoplasty is covered” section. New criteria states “For deformity caused by specifically documented trauma within the previous year.” Changed statement in billing and coding section to say “If documentation is requested, the following documentation should be supplied”

8/00 System coding changes.

9/00 Medical Policy Advisory Group reviewed. Approved. No change to criteria.

9/02 Specialty Matched Consultant Advisory Panel review 6/12/02. Criteria statement added in “When Rhinoplasty is covered” section – “For trauma-related nasal airway obstruction leading to chronic rhinosinusitis NOT RESPONDING TO MEDICAL THERAPY, regardless of date of injury.” Also for third bullet – “previous year” changed to “previous 18 months”. In “When Rhinoplasty is not covered”, “recent” clarified to “previous 18 months”.

3/04 Benefits Application and Billing/Coding sections revised.

9/9/04 Specialty Matched Consultant Advisory Panel review. First bullet under “When Covered” section revised as follows: “For deformities of the bony nasal pyramid (nasal bones and nasal process of the maxilla) that directly cause significant and symptomatic airway compromise, sleep apnea, or recurrent or chronic rhinosinusitis when these conditions are not responsive to appropriate medical management.” Under “Billing/Coding” section, first bullet revised to indicate that pre-operative photos must be submitted consisting at a minimum of legible frontal, lateral, and columellar views. First entry under “Scientific Background and Reference Sources” revised to indicate correct manual title. Notification given 9/9/04. Effective date 11/11/04.

10/2/06 Description section revised. When covered section reformatted and added the following to #2. “destructive inflammatory diseases (e.g., Wegener’s granulomatosis, pleomorphic granulomatosis)”. Removed “or disease” from When not Covered section – “For change in the external appearance of the nose in the absence of recent (i.e. within the previous 18 months) trauma or injury, or disease.” Medical term definition added. (pmo)

7/28/08 Under “When Covered” #1.a. Revised to “....sleep apnea or recurrent or chronic rhinosinusitis...”; #3-“For deformity caused by...” revised to “For deformity of the bony nasal pyramid caused by...” Under “When not Covered” added “For correction of vestibular stenosis and/or nasal valve collapse causing airway compromise but without nasal bony deformity requiring correction.” Added to “Policy Guidelines”. CPT codes 30460, 30462, 30465 added to “Billing/Coding” section. Specialty Matched Consultant Advisory Panel review- 6/23/08. References to trauma “within the previous 18 months” removed from “When Covered” section, #3 and from “When Not Covered” section, first bullet. Reference sources added. (pmo)

6/22/10 Policy Number(s) removed. (amw)

7/6/2010 Information added to Description section. Specialty Matched Consultant Advisory Panel review 5/24/10. No change to policy statement. (adn)

9/13/11 Specialty Matched Consultant Advisory Panel review 8/31/11. No change to policy statement or coverage criteria. (adn)

9/4/12 Reference added. Specialty Matched Consultant Advisory Panel review 8/15/12. No change to policy statement or coverage criteria. (sk)

1/14/14 Specialty Matched Consultant Advisory Panel review 8/21/13. Removed the statement “For correction of vestibular stenosis and/or nasal valve collapse causing airway compromise but without nasal bony deformity requiring correction” from the When Not Covered section. (sk)

10/14/14 Specialty Matched Consultant Advisory Panel review 9/30/14. No change to Policy statement. (sk)

10/1/15 Specialty Matched Consultant Advisory Panel review 8/26/15. (sk)

9/30/16 Reference added. Specialty Matched Consultant Advisory Panel review 8/31/2016. (sk)

9/15/17 Reference added. Specialty Matched Consultant Advisory Panel review 8/30/2017. (sk)

4/13/18 Code C9749 added to Billing/Coding section. Notification given 4/13/2018 for effective date 6/29/2018. (sk)

9/7/18 Specialty Matched Consultant Advisory Panel review 8/22/2018. (sk)

11/12/19 Specialty Matched Consultant Advisory Panel review 8/21/2019. (sk)

9/8/20 Specialty Matched Consultant Advisory Panel review 8/19/2020. Aging added to causes of internal nasal valve obstruction. Wegener’s granulomatosis changed to granulomatosis with polyangiitis (GPA). Code 30465 added to Billing/Coding section. (sk)

12/14/21 Specialty Matched Consultant Advisory Panel review 8/18/2021. (sk)

2/7/23 Specialty Matched Consultant Advisory Panel review 8/19/2022. (sk)

8/29/23 Updated references. Added Related Policy. Minor edit to the Policy Guidelines. No change to policy intent. Deleted terminated code C9749 from Billing/Coding section. Medical Director Review 8/2023. Specialty Matched Consultant Advisory Panel 8/2023. (ldh)

10/1/24 Updated references. Medical Director Review 8/2024. Specialty Matched Consultant Advisory Panel 8/2024. (ldh)