30120
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
5.26
Facility
$374.42
Non-Facility
$518.72
Documentation Required
- Photos that clearly document dynamic collapse or anatomic deformities narrowing the internal and/or External Nasal Valve or document rhinophyma or nasal bone/septal deviation as the primary cause of airway obstruction; photos must be consistent with clinical exam.
- Documented evidence of visible collapse of the alar (lower lateral) cartilage (External Nasal Valve) and/or lateral nasal wall (internal nasal valve) with deep inspiration for nasal valve repairs.
- Documented evidence of subjective and audible improvement in nasal airflow during a modified Cottle maneuver for nasal valve repairs.
- Surgeon's documentation specifying whether nasal valve compromise is static or dynamic, which valve(s) are involved (internal, External, or both), and a clearly stated surgical plan including the need for cartilage graft when applicable.
Key Coverage Criteria
- Nasal valve procedures/repair of nasal vestibular stenosis or alar collapse when ALL of the following are present: prolonged, persistent obstructed nasal breathing due to internal and/or External Nasal Valve compromise; other causes of nasal obstruction (e.g., rhinosinusitis, allergic rhinitis, vasomotor rhinitis, nasal polyposis, adenoid hypertrophy, and/or nasopharyngeal masses) have been adequately treated with maximal therapy and nasal obstruction persists; nasal septal deviation and turbina [...]
- Rhinophyma excision when ALL of the following are present: prolonged, persistent obstructed nasal breathing due to rhinophyma OR chronic infection or bleeding unresponsive to medical management due to rhinophyma; photos clearly document rhinophyma as the primary cause of an anatomic Mechanical Nasal Airway Obstruction or chronic infection and are consistent with the clinical exam; and the proposed procedure is designed to correct the anatomic Mechanical Nasal Airway Obstruction and relieve the N [...]
- Rhinoplasty for congenital anomalies when performed for a nasal deformity associated with congenital craniofacial anomalies (including but not limited to Pierre Robin syndrome, Apert syndrome, Fraser syndrome, Binder syndrome, Goldenhar syndrome, nasal dermoids, Tessier nasal cleft (most commonly no. 1), or associated with a cleft lip or cleft palate).
- Rhinoplasty-primary when ALL of the following are present: indication is one of (a) prolonged, persistent obstructed nasal breathing due to nasal bone and septal deviation that are the primary causes of an anatomic Mechanical Nasal Airway Obstruction; (b) nasal fracture with nasal bone displacement severe enough to cause nasal airway obstruction; or (c) residual large cutaneous defect following resection of a malignancy or nasal trauma; AND the Nasal Airway Obstruction cannot be corrected by sep [...]
- Rhinoplasty-revision when ALL of the following are present: required as treatment of a complication/residual deformity from primary surgery that was performed to address a Functional Impairment and a documented Functional Impairment persists due to the complication/deformity; photos clearly document the secondary deformity/complication as the primary cause of an anatomic Mechanical Nasal Airway Obstruction and are consistent with the clinical exam; the proposed procedure is designed to correct t [...]
- Rhinoplasty-tip when ALL of the following are present: prolonged, persistent obstructed nasal breathing due to tip drop that is the primary cause of an anatomic Mechanical Nasal Airway Obstruction; photos clearly document tip drop as the primary cause and are consistent with the clinical exam; the proposed procedure is designed to correct the anatomic Mechanical Nasal Airway Obstruction and relieve the obstruction by lifting the nasal tip; nasal airway obstruction is causing significant symptoms [...]
14 Active Policies
UHC-POL-rhinoplasty-other-nasal-surgeries — Rhinoplasty and Other Nasal Procedures
UMR-POL-UMR-rhinoplasty-other-nasal-surgeries — Rhinoplasty and Other Nasal Procedures
SUREST-POL-SUREST-rhinoplasty-other-nasal-surgeries — Rhinoplasty and Other Nasal Procedures
HUMANA-COSMETIC-AND-RECONSTRUCTIVE-SURGERY-SC-MEDICAID — Cosmetic and Reconstructive Surgery - MEDICAID - SOUTH CAROLINA
Related Codes
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