Latest Review Date: April 2024

Category: Surgery   

POLICY:

Septoplasty may be considered medically necessary for one of the following indications:

1. Continuous nasal obstruction clearly associated with a septal deviation upon physical exam of the nose which has not responded to appropriate medical therapy such as: trial of oral decongestants with or without antihistamine medicine and/or a trial of nasal steroid spray on a daily basis for 3 weeks (individual consideration is given for individuals with conditions that contraindicate treatment with these medications).

2. Chronic sinus infections where a deviated septum (confirmed by CT or sinus x-ray) is responsible for obstruction to the sinus drainage pathway that has been unresponsive to appropriate antibiotic therapy.
3. Evidence that sinus surgery is necessary because chronic sinusitis fails to resolve with non-surgical measures and a deviated septum (confirmed by CT or sinus x-ray) limits the ability of the surgeon to pass endoscopic instruments to perform the necessary surgery.
4. In rare circumstances, the deviation of the septum impacts against the side-wall of the nasal passage or turbinate causing what is known as rhinogenic headache. Headaches are diagnosed by applying a local anesthetic against the deviation during a headache to see if is relieved for the duration of the anesthetic/action. Procedure may be repeated to clearly define causation.  This procedure must be performed and documented that relief was obtained prior to recommendation for surgery.
5. Severe or frequent epistaxis due to localized drying of the membrane of a deviated septum that occurs despite medical measures.
6. Asymptomatic deformity severe enough to prevent surgical access to other inner nasal areas that require surgical intervention.
7. Nasal trauma resulting in nasal airway obstruction that was not present prior to the injury.

Rhinoplasty may be considered medically necessary for the treatment of a nasal deformity due to trauma, disease or injury under the following conditions:

1. There is documentation of the events related to the deformity/trauma and preoperative photographs (full face and lateral views).
2. Nasal obstruction related to trauma, disease or injury.
3. If available but not required, radiologic confirmation of either a comminuted nasal fracture or peri-nasal fracture.

Rhinoplasty is considered not medically necessary when performed for reshaping the nose to improve appearance and is considered cosmetic.

Septorhinoplasty may be considered medically necessary when criteria for the septoplasty and rhinoplasty are met.

DESCRIPTION OF PROCEDURE OR SERVICE:

Septoplasty is the surgical procedure designed to correct a nasal septum deviation, which is causing either a partial restriction or nearly complete restriction of airflow through the nose. The nasal septum is the part of the nose that divides the nasal airway into two passages.  Generally, the septum lies directly in the center of the nose, but is rarely perfectly straight.  The septum may be off-center or deviated to such an extent that the curvature impedes airflow and causes an obstruction, creating a breathing impairment. When the septum is off-center or misaligned, a septoplasty may also be referred to as a submucosal resection of the septum and may be performed for reasons other than to correct a breathing impairment.

Rhinoplasty is a surgical procedure for correcting traumatic and functional deformities as well as for cosmetic enhancement by reshaping the nose. Although it is typically performed for cosmetic purposes to correct or improve the external appearance of the nose, there may be situations when rhinoplasty may be considered reconstructive. 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, and cleft lip nasal deformities.

KEY POINTS:

The literature review for this policy was performed through April 11, 2024.

KEY WORDS:

Septoplasty, nasal septum, deviated nasal septum, rhinoplasty, cosmetic, septorhinoplasty, turbinate

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.

CURRENT CODING:

CPT codes:  

REFERENCES:

1. Althobaiti KH, Fida AR, Almahmoudi A, AlGhamdi D, Alharbi M. Common Causes of Failed Septoplasty: A Systematic Review. Cureus. 2022 Dec 28;14(12): e33073
2. American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). Clinical Consensus Statement: septoplasty with or without inferior turbinate reduction. Otolaryngol Head Neck Surg. 2015; 153(5):708-720. oto.sagepub.com/content/153/5/708.full.pdf+html.
3. American Society of Plastic Surgeons. Rhinoplasty surgery of the nose, www.plasticsurgery.org/public_education/procedures/Rhinoplasty.
4. Fichman M, Piedra Buena IT. Rhinoplasty. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 12, 2023.
5. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
6. Ishii LE, Tollefson TT, Basura GJ,et.al. Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty. Otolaryngol Head Neck Surg, 2017; 156 (2_suppl): S1-S30.
7. Na'ara S, Kaptzan B, Gil Z, Ostrovsky D. Endoscopic Septoplasty Versus Traditional Septoplasty for Treating Deviated Nasal Septum: A Prospective, Randomized Controlled Trial. Ear Nose Throat J. 2021 Nov;100(9):673-678.
8. National Institute of Health.  MEDLINEplus Medical Encyclopedia: Cosmetic nose surgery, www.nlm.nih.gov/medlineplus/ency/article/002983.htm.
9. National Institute of Health.  MEDLINEplus Medical Encyclopedia: Septoplasty, www.nlm.nih.gov/medlineplus/ency/article/003012.htm.
10. Rohrich RJ, Hollier LH. Rhinoplasty with advancing age: characteristics and management. Otolaryngol Clin North Am. 1999;32(4): 755-773
11. Watson, Deborah. Septoplasty, www.emedicine.com/ent/topic128.htm. Published Jul 28, 2023.

POLICY HISTORY:

Medical Policy Group, April 2003 (1)

Medical Policy Administration Committee, April 2003

Available for comment July 1-August 14, 2003

Available for comment August 28-October 13, 2003

Medical Policy Group, April 2005 (1)

Medical Policy Group, October 2007 (1)

Medical Policy Group, October 2009 (1)

Medical Policy Group, February 2011(3): Effective 1/1/2011: Active policy but no longer scheduled for regular literature reviews and updates.

Medical Policy Group, April 2015 (3): No new information identified that would alter coverage statement at this time; no changes in consensus. Policy removed from update schedule.

Medical Policy Group, October 2019 (6): Updates to Description, Key Points, Coding (30460, 30462) and References. No change to policy intent.

Medical Policy Group, March 2021 (5): Minor update to Key Points. Reviewed by consensus. No new literature identified that would alter coverage statement at this time.

Medical Policy Group, March 2022 (5): Minor update to Key Points and References. Reviewed by consensus. No new literature identified that would alter coverage statement at this time.

Medical Policy Group, March 2023 (5): Updates to Key Points, Benefit Application, and References. Reviewed by consensus. No new literature identified that would alter coverage statement at this time.

Medical Policy Group, April 2024 (9): Reviewed by consensus. No new published peer-reviewed literature is available that would alter the coverage statement in this policy. Updates to Key Points, Benefit Application, and References. No change to the policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.