Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Septoplasty, Rhinoplasty, and Septorhinoplasty

Policy #:11.16.01h

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

SEPTOPLASTY

When performed as a cosmetic service, septoplasty is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration.

MEDICALLY NECESSARY
Septoplasty as a stand-alone procedure is considered medically necessary and, therefore, covered when used to treat a septal deformity resulting in any of the following conditions:
  • Continuous nasal airway obstruction when both of the following criteria are met:
    • The space between the inferior turbinate and the septum is decreased by an overall clinical estimate of greater than 75 percent (e.g., turbinate hypertrophy, septal deviation).
    • A recent four week trial of conservative medical therapy (e.g., decongestants, nasal spray, corticosteroids) has been ineffective in treating the obstruction, which can only be corrected by surgery.
  • Recurrent sinusitis documented by four or more episodes of acute sinusitis per year treated with antibiotics and/or other medications, each lasting more than seven days, with an absence of symptoms between episodes (without antibiotic therapy)
  • Recurrent epistaxis (i.e., nose bleed)
  • Asymptomatic septal deformity that prevents access to other intranasal or paranasal areas (e.g., sinuses, turbinates) required to perform medically necessary procedures (e.g., ethmoidectomy, turbinectomy)
  • Obstructed nasal breathing interfering with effective use of medically necessary continuous positive airway pressure (CPAP) for the treatment of obstructive sleep disorder when a recent four week trial of conservative medical therapy (e.g., decongestants, nasal spray, corticosteroids) has been ineffective in treating the obstruction, which can only be corrected by surgery.

Septoplasty when performed in association with cleft lip and/or cleft palate repair is considered medically necessary and, therefore, covered to correct a congenital defect that causes significant impairment of nasal function.

RHINOPLASTY AND SEPTORHINOPLASTY

When performed as a cosmetic service, rhinoplasty and septorhinoplasty are benefit contract exclusions for all products of the Company and are not eligible for reimbursement consideration.

MEDICALLY NECESSARY
Rhinoplasty and septorhinoplasty are considered medically necessary and, therefore, covered when the individual has a significant impairment of nasal function caused by both of the following:
  • Structural nasal and/or septal deformities caused by any of the following:
    • Trauma (e.g., nasal fracture)
    • Disease (e.g., tumor, infection)
    • Congenital defect (e.g., cleft lip and/or palate)
  • Continuous nasal and/or septal obstruction when both of the following criteria are met:
    • The space between the inferior turbinate and the septum is decreased by an overall clinical estimate of greater than 75 percent (e.g. turbinate hypertrophy, septal deviation).
    • A recent four week trial of conservative medical therapy (e.g., decongestants, nasal spray, corticosteroids) has been ineffective in treating the obstruction, which can only be corrected by surgery.

Rhinoplasty is considered medically necessary and, therefore, covered when the individual has a significant impairment of nasal function caused by chronic non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).

COSMETIC

Septoplasty, rhinoplasty, and septorhinoplasty that do not meet the medical necessity criteria listed in this policy are considered cosmetic services. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request.
For septoplasty, rhinoplasty, or septorhinoplasty, this includes the following:
  • Results of any clinically indicated diagnostic studies to document the deformity and/or obstruction:
    • Diagnostic nasal airflow studies (e.g., rhinometry, rhinomanometry)
    • Nasal endoscopy
    • Anterior rhinoscopy
    • CT scan
  • Letter of medical necessity from the professional provider
    • Documented severity and duration of symptoms caused by the deformity and/or obstruction
    • Documented relevant history of trauma, disease, or congenital defect
  • Photographs of the frontal, lateral, and submental views of the face for rhinoplasty or septorhinoplasty

Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Claims submitted for septoplasty (Current Procedural Terminology [CPT] code 30520) must include a primary diagnosis code (International Classification of Disease [ICD]-10) to represent septal/nasal deformity, which are listed within the coding table of this policy.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, septoplasty, rhinoplasty, and septorhinoplasty are covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

Individuals who have structural nasal and/or septal deformities caused by trauma and/or accident (e.g., nasal bone fracture), disease (e.g., tumor, infection), or congenital defect (e.g., cleft lip and/or palate) often experience impaired breathing. Septoplasty, rhinoplasty, or septorhinoplasty are surgical procedures that may be performed to correct external nasal deformities or nasal airway obstructions, or to repair a congenital defect.

Septoplasty corrects defects or deformities of the nasal septum by altering, splinting, or removing obstructive supporting structures. Septoplasty is often performed as a stand-alone surgery to restore function and improve airflow through the breathing passages.

Rhinoplasty changes the shape and size of the nose. Incisions are made, and parts of the underlying bone and cartilage may be removed, added to, or rearranged to provide a newly shaped structure. The tissues are then placed over the new frame, and the incisions are closed. Post-operatively, a splint is used to retain the new shape of the nose as it heals. Absorbent packing and soft nasal supports may be placed inside the nose to maintain stability along the septum or divide the walls of the airways.

A reconstructive rhinoplasty restores function or corrects a structural nasal deformity due to trauma and/or accident (e.g., nasal fracture), disease (e.g., tumor, infection), or congenital defect (e.g., congenital cleft lip, cleft nose, and/or palate). While reconstruction is typically performed to improve function, it may also be done to approximate a more normal-looking appearance.

A cosmetic rhinoplasty or septoplasty reshapes normal nasal structures that have no functional deficits in order to aesthetically enhance an individual's appearance. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

When septoplasty is performed during the same operative session as rhinoplasty (for either cosmetic or reconstructive purposes), the entire procedure is referred to as septorhinoplasty.
References


American Academy of Allergy Asthma & Immunology (AAAAI). The diagnosis and management of sinusitis. A practice parameter update. [AAAAI Web site]. 2005. Available at: https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20and%20Parameters/sinusitis2005.pdf. Accessed August 28, 2018.

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Rhinoplasty. [AAFPRS Web site]. 2018. Available at: http://www.aafprs.org/patient/procedures/rhinoplasty.html. Accessed August 28, 2018.

American Academy of Otolaryngology Head and Neck Surgery (AAOHNS). Deviated septum. [AAOHNS Web site]. 2018. Available at: http://www.entnet.org/content/deviated-septum. Accessed August 28, 2018.

American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. [ASPS Web site]. July 2006. Available at:http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Nasal-Surgery-Insurance-Coverage.pdf. Accessed August 28, 2018.

American Society of Plastic Surgeons (ASPS). Practice parameter. Nasal surgery. [ASPS Web site]. July 2006. Available at:http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Nasal-Surgery-Practice-Parameter.pdf. Accessed August 28, 2018.

American Society of Plastic Surgeons (ASPS). Rhinoplasty nose surgery. [ASPS Web site]. 2018. Available at: https://www.plasticsurgery.org/cosmetic-procedures/rhinoplasty. Accessed August 28, 2018.

Bhattacharyya N. Clinical presentation, diagnosis, and treatment of nasal obstruction. [UpToDate Web site]. 05/07/2018. Available at:
https://www.uptodate.com/contents/clinical-presentation-diagnosis-and-treatment-of-nasal-obstruction?source=search_result&search=septoplasty&selectedTitle=1~11 [via subscription only]. Accessed August 28, 2018.

Bennett GH. Turbinate Hypertrophy. [New York Sinus Surgery Web site]. 2017. Available at: https://www.sinussurgeryprocedure.com/turbinate-hypertrophy/. Accessed September 14, 2018.

Bitar MA, Birjawi G, Youssef M, Fuleihan NS. Nasal obstruction in children: Evaluation of common assessment methods. August 2004. Available at: http://www.sciencedirect.com/science/article/pii/S0194599804010903. Accessed August 28, 2018.

Fuller JC, Levesque PA, Lindsay RW. Functional septorhinoplasty in the pediatric and adolescent patient. Int J Pediatr Otorhinolaryngol. 2018; 111:97-102.

Han JK, Stringer SP, Rosenfeld RM, et al. Clinical consensus statement: septoplasty with or without inferior turbinate reduction. Otolaryngology–Head and Neck Surgery.2015;153(5):708–720.

Isaacson GC, Messner AH, Armsby C. Congenital anomalies of the nose. [UpToDate Web site]. 05/25/2018. Available at: https://www.uptodate.com/contents/congenital-anomalies-of-the-nose?topicRef=14609&source=see_link [via subscription only]. Accessed August 17, 2018.

Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty. Otolaryngology–Head and Neck Surgery.2017;156(2S):S1–S30.

Jin HR, Kim DW, Jung HJ. Common Sites, Etiology, and Solutions of Persistent Septal Deviation in Revision Septoplasty. Clin Exp Otorhinolaryngol. 2018. [Epub ahead of print].

Manteghi A, Din H, Bundogji N, Leuin SC. Pediatric septoplasty and functional septorhinoplasty: A quality of life outcome study. Int J Pediatr Otorhinolaryngol. 2018; 111: 12-20.

Marks MW, Marks C. Aesthetic facial surgery. In: Fundamentals of Plastic Surgery. Philadelphia, PA: WB Saunders Co; 1997:258-264.

Novitas Solutions, Inc. Local Coverage Determination (LCD). (L35090): Cosmetic and reconstructive surgery. [Novitas Solutions, Inc. Web site]. 04/14/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=45&CntrctrType=12&KeyWord=cosmetic&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&. Accessed August 28, 2018.

Romo T, Pearson JM, Presti P, Yalamanchili H. Rhinoplasty, postrhinoplasty nasal obstruction: workup. [eMedicine Web site]. 06/07/12. Available at: http://emedicine.medscape.com/article/841574-diagnosis. Accessed August 28, 2018.

Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngol Head Neck Surg. 2015; 152(2S):S1-S39.

Shah J, Roxbury CR, Sindwani R. Techniques in Septoplasty: Traditional Versus Endoscopic Approaches. Otolaryngol Clin N Am. 2018; S0030-6665(18):30093-8.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30520


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

SEPTOPLASTY IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES

J34.2 Deviated nasal septum

J34.3 Hypertrophy of nasal turbinates

J34.89 Other specified disorders of nose and nasal sinuses

M95.0 Acquired deformity of nose

Q30.0 Choanal atresia

Q30.1 Agenesis and underdevelopment of nose

Q30.2 Fissured, notched and cleft nose

Q30.3 Congenital perforated nasal septum

Q30.8 Other congenital malformations of nose

Q30.9 Congenital malformation of nose, unspecified

Q35.1 Cleft hard palate

Q35.3 Cleft soft palate

Q35.5 Cleft hard palate with cleft soft palate

Q35.7 Cleft uvula

Q35.9 Cleft palate, unspecified

Q36.0 Cleft lip, bilateral

Q36.1 Cleft lip, median

Q36.9 Cleft lip, unilateral

Q37.0 Cleft hard palate with bilateral cleft lip

Q37.1 Cleft hard palate with unilateral cleft lip

Q37.2 Cleft soft palate with bilateral cleft lip

Q37.3 Cleft soft palate with unilateral cleft lip

Q37.4 Cleft hard and soft palate with bilateral cleft lip

Q37.5 Cleft hard and soft palate with unilateral cleft lip

Q37.8 Unspecified cleft palate with bilateral cleft lip

Q37.9 Unspecified cleft palate with unilateral cleft lip

Q67.4 Other congenital deformities of skull, face and jaw

Q75.8 Other specified congenital malformations of skull and face bones

Q75.9 Congenital malformation of skull and face bones, unspecified

RHINOPLASTY AND SEPTORHINOPLASTY ARE MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES

C30.0 Malignant neoplasm of nasal cavity

C41.0 Malignant neoplasm of bones of skull and face

C43.31 Malignant melanoma of nose

C43.39 Malignant melanoma of other parts of face

C44.301 Unspecified malignant neoplasm of skin of nose

C44.309 Unspecified malignant neoplasm of skin of other parts of face

C44.311 Basal cell carcinoma of skin of nose

C44.319 Basal cell carcinoma of skin of other parts of face

C44.321 Squamous cell carcinoma of skin of nose

C44.329 Squamous cell carcinoma of skin of other parts of face

C44.391 Other specified malignant neoplasm of skin of nose

C44.399 Other specified malignant neoplasm of skin of other parts of face

C76.0 Malignant neoplasm of head, face and neck

D03.39 Melanoma in situ of other parts of face

D04.30 Carcinoma in situ of skin of unspecified part of face

D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses

D16.4 Benign neoplasm of bones of skull and face

D22.30 Melanocytic nevi of unspecified part of face

D23.30 Other benign neoplasm of skin of unspecified part of face

J32.0 Chronic maxillary sinusitis

J32.1 Chronic frontal sinusitis

J32.2 Chronic ethmoidal sinusitis

J32.3 Chronic sphenoidal sinusitis

J32.4 Chronic pansinusitis

J34.0 Abscess, furuncle and carbuncle of nose

J34.1 Cyst and mucocele of nose and nasal sinus

J34.2 Deviated nasal septum

J34.3 Hypertrophy of nasal turbinates

J34.89 Other specified disorders of nose and nasal sinuses

Q30.0 Choanal atresia

Q30.8 Other congenital malformations of nose

Q35.1 Cleft hard palate

Q35.3 Cleft soft palate

Q35.5 Cleft hard palate with cleft soft palate

Q35.7 Cleft uvula

Q36.0 Cleft lip, bilateral

Q36.1 Cleft lip, median

Q36.9 Cleft lip, unilateral

Q37.0 Cleft hard palate with bilateral cleft lip

Q37.1 Cleft hard palate with unilateral cleft lip

Q37.2 Cleft soft palate with bilateral cleft lip

Q37.3 Cleft soft palate with unilateral cleft lip

Q37.4 Cleft hard and soft palate with bilateral cleft lip

Q37.5 Cleft hard and soft palate with unilateral cleft lip

Q37.8 Unspecified cleft palate with bilateral cleft lip

Q37.9 Unspecified cleft palate with unilateral cleft lip

Q67.0 Congenital facial asymmetry

Q67.1 Congenital compression facies

Q67.2 Dolichocephaly

Q67.3 Plagiocephaly

Q67.4 Other congenital deformities of skull, face and jaw

R04.0 Epistaxis

R09.81 Nasal congestion

S02.2XXA Fracture of nasal bones, initial encounter for closed fracture

S02.2XXB Fracture of nasal bones, initial encounter for open fracture

S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing

S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing

S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion

S02.2XXS Fracture of nasal bones, sequela



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.16.01h:
09/26/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 10/10/2017
Version Issued Date: 10/10/2017
Version Reissued Date: 09/26/2018

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