Subject:
Rhinoplasty
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Nasal surgical procedures performed to alter the structure and external appearance of the nose.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Rhinoplasty is generally considered cosmetic and not medically necessary.
2. For a procedure to be considered medically necessary, copies of original medical records must be submitted either hard copy or electronically to support an episode of physical trauma and/or medical necessity. It should include but not be limited to:
- detailed history and physical examination including, where appropriate, documentation of physical trauma, copies of report of any testing (CT, MRI, x-rays, etc. including intranasal examination);
- documentation of a chronic nasal problem which has failed medical management;
- when there has been previous surgery, copies of all previous operative reports, assessment of how proposed surgery will alleviate problem, and why problem was not relieved by previous surgery;
- documentation from the treating physician(s) indicating medical necessity for the procedure including medical problems directly attributed to the existing nasal structure and extent of functional impairment as it relates to activities of daily living or occupation;
- close-up nasal photographs - three (3) views AP, LAT, and Nares/Basal.
[INFORMATIONAL NOTE: We frequently receive requests and/or claims for septal or other intranasal dermatoplasty (CPT code 30620), turbinectomy (CPT code 30140/30130), and nasal valve repair (CPT code 30465) along with requests/claims for rhinoplasty. Consultations with ENT experts lead us to believe that intranasal dermatoplasty is rarely necessary except in cases of Osler-Weber-Rendu's disease and telangectasias of the nose. Similarly, turbinectomies and "nasal valve" surgery are rarely medically necessary and documentation justifying the need for these procedures should be submitted.]
Medicare Coverage:
There is no National Coverage Determination (NCD) for rhinoplasty. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that this service is covered when LCD L35090 criteria are met. For eligibility and coverage, please refer to Novitas Solutions Inc, LCD L35090 Cosmetic and Reconstructive Surgery. Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Required Documentation:
1. The medical record must include photographic documentation of the following: frontal, lateral and worm’s eye view of the individual’s condition.
2. The medical record must include a description of the condition requiring the rhinoplasty.
3. When performed for chronic obstruction the medical record must indicate what is causing the obstruction.
4. The medical record should include a description of any conservative treatment that has been utilized to treat obstruction and the length of time that the conservative treatment has been trialed.
When nasal surgery, including rhinoplasty, is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure should be considered reconstructive.
Rhinoplasty is not covered when performed solely for the purpose of changing appearance.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Rhinoplasty
References:
1. Schlosser RJ, Park SS. Functional nasal surgery. Otolaryngologic Clinics of North America. 1999 February;32(1):37-51.
2. American Society of Plastic Surgeons. Nasal Surgery: Recommended Criteria for Third-Party Payer Coverage. Approved July 2006. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Nasal-Surgery-Insurance-Coverage.pdf (accessed 11/20/14)
3. American Academy of Otolaryngology - Head and Neck Surgery. Clinical Indicators: Rhinoplasty. Available at http://www.entnet.org/sites/default/files/Rhinoplasty-CI%20Updated%208-7-14.pdf (accessed 11/20/14)
4. UpToDate. Etiologies of nasal symptoms: An overview. Literature review current through November 2016. Topic last updated May 10, 2016.
5. UpToDate. Clinical presentation, diagnosis, and treatment of nasal obstruction. Literature review current through November 2016. Topic last updated July 12, 2016.
6. Bhattacharyya N. Clinical presentation, diagnosis, and treatment of nasal obstruction. In: UpToDate, Deschler DG, Sullivan DJ (Eds), UpToDate, Waltham, MA. (Accessed on September 6, 2017.)
7. Bhattacharyya N. Clinical presentation, diagnosis, and treatment of nasal obstruction. In: UpToDate, Deschler DG, Sullivan DJ (Eds), UpToDate, Waltham, MA. (Accessed on August 9, 2018.)
8. Bhattacharyya N. Clinical presentation, diagnosis, and treatment of nasal obstruction. In: UpToDate, Deschler DG, Kunins L. (Eds), UpToDate, Waltham, MA. (Accessed on August 21, 2019.)
9. Phillips KA. Body dysmorphic disorder: Clinical features. In: UpToDate, Dimsdale J, Solomon D. (Eds), UpToDate, Waltham, MA. (Accessed on August 21, 2019.)
10. Isaacson GC. Congenital anomalies of the nose. In: UpToDate, Messner AH, Armsby C. (Eds), UpToDate, Waltham, MA. (Accessed on August 21, 2019.)
11. Bhattacharyya N. Nasal Obstruction: Diagnosis and management. In: UpToDate, Deschler DG, Kunins L. (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
12. Phillips KA. Body dysmorphic disorder: Clinical features. In: UpToDate, Dimsdale J, Solomon D. (Eds), UpToDate, Waltham, MA.(Accessed on August 19, 2020.)
13. Isaacson GC. Congenital anomalies of the nose. In: UpToDate, Messner AH, Armsby C. (Eds), UpToDate, Waltham, MA. (Accessed on August 19, 2020.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
30400
30410
30420
30430
30435
30450
30460
30462
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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