Rhinoplasty is a surgical procedure performed to correct nasal contour and/or restore nasal function. Correction of a nasal deformity by rhinoplasty is done to improve the airway, provide balance to the face and/or to improve appearance.
Rhinoplasty is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Rhinoplasty for the purpose of altering the external appearance of the nose in the absence of disease, trauma or injury is considered cosmetic.
Rhinoplasty for the purpose of correcting a nasal deformity due to a previous cosmetic surgery is considered cosmetic.
Rhinoplasty is considered medically appropriate with ALL of the following:
Procedure is indicated for ANY ONE of the following:
Airway obstruction from deformity due to ANY ONE of the following:
Injury that is not treatable with conservative measures
Nasal deformity due to ANY ONE of the following:
Disease (e.g., deformity caused by surgery for nasal malignancy)
Trauma or injury
Condition cannot be corrected by septoplasty and/or turbinectomy
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Manafi, A., Hamedi, Z., Manafi, A., Rajabiani, A., Rajaee, A., and Manafi, F. (2015). Injectable cartilage shaving: an autologous and long lasting filler material for correction of minor contour deformities in rhinoplasty. World Journal of Plastic Surgery, 4 (2), 93-100. (Level 4 evidence)
Ramos, T., de Brito, M., Piccolo, M., Rosella, M., Neto, M., and Ferreira, L. (2016) Body dysmorphic symptoms scale for patients seeking esthetic surgery: cross-cultural validation study. San Paulo Medical Journal; 2016; 134(6):480-90. (Level 4 evidence)Wisconsin Physician Services, Insurance Corporation (2017, January) Local Coverage Determination (LCD) for cosmetic and reconstructive surgery (L34698). Retrieved June 6, 2017 from: http://www.cms.gov.
ORIGINAL EFFECTIVE DATE: 10/1999
MOST RECENT REVIEW DATE: 7/13/2017
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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