Medicare Advantage

Medical Policy

Notification

Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty

Notification Issued Date: 12/26/2025 9:00 AM

This policy will become effective 03/30/2026.

The following have been revised in this policy:

Septoplasty

Removed the required documentation of a 4-week conservative medical trial and 75% nasal obstruction threshold. Documentation of an attempted medical trial is still required.

Rhinoplasty/Septorhinoplasty

Revised the lead-in sentence where an individual no longer needs to meet both of the criteria. An individual is eligible if they meet any of the criteria listed in this section.
Removed the required documentation of a 4-week conservative medical trial and 75% nasal obstruction threshold.
Revised language to indicate that nasal airway obstructions secondary to trauma, disease, and/or congenital defects are medically necessary only if the nasal obstruction is unresolved, or not expected to resolve, after septoplasty/turbinectomy
Added a new medically necessary indication for when a nasal deformity is secondary to cleft lip/palate or other congenital craniofacial deformity causing a functional impairment

The following ICD-10 codes have been removed from this policy:

C44.301, C44.309, D04.30, D22.30, D23.30, J34.3, J34.8200, J34.8210, J34.829, M95.0,Q30.1, Q30.2, Q30.3, Q30.9, Q35.9, Q37.8, Q37.9, S02.2XXD, S02.2XXG, S02.2XXK, S02.2XXS

Title:

Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty

Policy #:

MA11.099f

Policy

This policy uses coverage criteria primarily based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. In the absence of fully established coverage criteria from these Medicare coverage documents for a specific medical service or item, the criterion/indication/service indicated by an asterisk below (*) is based on internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, regulatory status, and/or expert opinion.

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 is considered medically necessary and, therefore, covered when the individual has any of the following conditions:

Septal deviation/deformity causing nasal airway obstruction (NAO) that has proved unresponsive to a recent trial of conservative medical management (e.g., topical nasal corticosteroids, nasal decongestants, nasal dilators).

This includes NAOs interfering with the effective use of medically necessary continuous positive airway pressure (CPAP) for the treatment of an obstructive sleep disorder.

Recurrent rhinosinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy
Recurrent epistaxis (i.e., nose bleed) related to a septal deviation/deformity
When performed in association with cleft lip or cleft palate repair
Asymptomatic septal deviation/deformity that prevents access to other transnasal areas to perform medically necessary procedures (e.g., ethmoidectomy, turbinectomy)

RHINOPLASTY AND SEPTORHINOPLASTY

When performed as a cosmetic service, rhinoplasty and septorhinoplasty are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, these procedures are not eligible for reimbursement consideration.

MEDICALLY NECESSARY
Rhinoplasty and septorhinoplasty are considered medically necessary and, therefore, covered when the individual has any of the following:

NAO that has not resolved—or would not be expected to resolve—after previous septoplasty/turbinectomy, and is secondary to any of the following:

Trauma (e.g., nasal fracture)
Disease (e.g., tumor, infection)
Congenital defect (e.g., cleft lip and/or palate)

Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment
Chronic nonseptal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves)

DERMABRASION FOR THE TREATMENT OF RHINOPHYMA

When performed as a cosmetic service, dermabrasion is not covered by the Company because cosmetic services are not covered by Medicare. Therefore, this procedure is not eligible for reimbursement consideration.

MEDICALLY NECESSARY

Dermabrasion is considered medically necessary and, therefore, covered when the individual has a significant impairment of nasal function, such as airway obstruction, caused by rhinophyma.

EXPERIMENTAL/INVESTIGATIONAL

Low-energy radiofrequency intranasal tissue remodeling (e.g., VivAer System) for the treatment of NAO is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature* (Han et al., 2025; Han et al., 2024; Han et al., 2022; Silvers et al., 2024; Silvers et al., 2021; Yao et al., 2025; Yao et al., 2023).

COSMETIC

Septoplasty, rhinoplasty, septorhinoplasty, and dermabrasion that do not meet the medical necessity criteria listed in this policy are considered cosmetic services. Services that are cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. 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 not covered by Medicare.

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.

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, 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
- Computed tomography (CT) scan
Letter of medical necessity from the professional provider
- Documented severity and duration of symptoms caused by the deformity and/or obstruction (e.g., rhinosinusitis episodes, mouth breathing, difficulty sleeping, nasal congestion)
- Documented relevant history of prior medications (e.g., antibiotics, steroids, immunotherapy) and/or nasal interventions (e.g., nasal dilators, surgery) and the length of treatment duration
- 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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, septoplasty, rhinoplasty, septorhinoplasty, and dermabrasion are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable Evidence of Coverage, low-energy radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction is not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are excluded for the Company’s Medicare Advantage products. Therefore, they are not eligible for reimbursement consideration.

Services that are identified in this policy as cosmetic are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Aerin Medical Inc. first received FDA 510(k) premarket notification clearance for the Aerin Console and InSeca ARC Stylus on January 11, 2017 (K162810). A second clearance was granted on December 5, 2017, for the VivAer ARC Stylus, which was deemed substantially equivalent to the InSeca ARC Stylus (K172529). A third clearance was granted on April 13, 2020, for the VivAer Stylus, which was deemed substantially equivalent in function, design, and intended use to the VivAer ARC Stylus (K200300). The VivAer Stylus is indicated for use in otorhinolaryngology (ENT) surgery for the coagulation of soft tissue in the nasal airway, to treat nasal airway obstruction by shrinking submucosal tissue, including cartilage in the internal nasal valve area.

Description

Nasal airway obstruction (NAO) is a condition characterized by impaired breathing and insufficient airflow through the nasal passages. Structural alterations within the internal nasal anatomy—such as deviations in the turbinates, septum, and/or ostiomeatal complex—can significantly affect an individual’s perception of airflow. NAO commonly arises from a range of mechanical and mucosal causes, with deviated nasal septum being one of the most prevalent conditions; however, the underlying pathophysiology is often multifactorial. There is currently no universally accepted standard for quantifying the degree of nasal obstruction, as objective assessments (e.g., acoustic rhinometry, peak nasal airflow, rhinomanometry) may not correlate with subjective symptoms. Instead, clinicians rely on a combination of patient-reported outcomes (e.g., the Nasal Obstruction Symptom Evaluation [NOSE] score) alongside medical history and physical examination.

Septoplasty, rhinoplasty, or septorhinoplasty are surgical procedures that may be performed to correct NAO. 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. Postoperatively, 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 can correct anatomic nasal airway deformities that compromise airflow, such as traumatic deformities, narrow bony aperture, or abnormally small nares. Although 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.

Dermabrasion is a form of skin resurfacing used to remove damaged skin and promote normal wound healing and skin rejuvenation. Standard dermabrasion uses a wire brush or a stainless steel wheel on which diamond chips have been bonded (diamond fraise abraders) to plane the skin, whereas laser dermabrasion involves use of the argon laser, ultrapulse carbon dioxide (CO₂) laser, or flashlamp-pumped pulsed dye laser. Dermabrasion is used for the treatment of many different dermatological conditions such as acne scars, wrinkles, and different forms of rosacea. The treatments of these conditions are considered cosmetic as they are usually not associated with any functional impairment or deformities. Rhinophyma is characterized by skin thickening, which can cause an enlargement of the nose due to excess tissue and overgrowth of sebaceous glands. Rhinophyma may pose functional problems such as NAO, including sleep apnea.The treatment of this condition is to remove the hypertrophic skin. There are several different procedures used to treat rhinophyma but there is not a consensus of a gold standard treatment.

TEMPERATURE CONTROLLED RADIOFREQUENCY (TCRF) DEVICES (E.G., VIVAER SYSTEM)

TCRF devices are used in a noninvasive office-based procedure as an alternative to invasive surgical interventions. VivAer (Aerin Medical Inc.) is a type of TCRF device intended to modify the soft tissue of the nasal airway using low-dose nonablative radiofrequency (RF) energy for the treatment of nasal valve collapse (NVC). The RF energy can be used to remodel nasal cartilage and soft tissue throughout the nasal valve, including the septum, the inferior turbinate, and the nasal valve itself. Current standard practice for individuals with severe to extreme NAO who have exhausted conservative therapies (e.g., medication, stents) is typically surgery. TCRF was introduced as a less invasive option for similar indications.

Due to the lack of standardization regarding objective clinical outcome measures for diagnosing NAO, patient-reported measures (e.g., nasal obstruction symptom evaluation [NOSE]) are often the gold standard for understanding intervention efficacy before and after the procedure. The NOSE scale differentiates severity into the following categories: Mild (5−25), moderate (30−50; NAO threshold), severe (55−75), and extreme (80−100) (Lipan et al., 2013). A moderate or higher score is associated with difficulty performing daily activities (e.g., sleeping, congestion, trouble breathing when sitting or exercising). Individuals may receive further treatment if they have a moderate or greater score, considering these individuals have difficulty performing activities of daily living (e.g., sleeping, congestion, trouble breathing when sitting and/or exercising).

Outcomes essential for determining treatment efficacy when patient-reported scores are the primary endpoint, include measuring the mean change in NOSE score from baseline, as well as the minimum clinically important difference (MCID). The MCID is needed for assessing the extent of a clinically meaningful treatment effect from a population standpoint, representing the smallest change in an outcome that clinicians or patients would perceive as significant.

SUMMARY OF VIVAER EVIDENCE

The aggregate literature using VivAer for the treatment of NAO appears to demonstrate some meaningful change from baseline using relevant outcomes of interest. Nevertheless, significant limitations in the evidence remain that are not adequately addressed in recent literature. For example, Yao et al. (2023, 2025) showed NOSE score improvement sustained up to 3 years, but the high attrition and no sham or head-to-head comparator preclude conclusions on any potential long-term benefit from TCRF. One study attempted to mitigate this limitation by incorporating a sham control (Silvers et al., 2021, 2024; Han et al., 2022, 2025). Treatment efficacy was demonstrated over the sham group up to 3 months; however, the sham cross-over after 3 months gives pause to the durability of VivAer, regardless of any subsequent follow-up periods. Han et al. (2024) tried to address these limitations in a systematic review and meta-analysis using a matched comparator, but the indirect nature of the controls, combined with substantial variability within the study groups, limits confidence in both the long-term efficacy findings and how the device measures up to established treatments. At this time, there are no randomized controlled trials (RCTs) that make a direct comparison of VivAer to current surgical interventions, nor long-term sham-controlled trials. In consideration of the overall limitations, the available literature for VivAer is unable to establish safety and efficacy and fails to meet the clinical gap in the current standard of care.

EVIDENTIARY REVIEW OF VIVAER

Although there are other TCRF devices, VivAer is the only device with US Food and Drug Administration approval for the treatment of nasal valve collapse. Preferred studies considered for analysis are systematic review and meta-analyses and RCTs. Prospective single-arm clinical trials and case reports/series may be considered to supplement the available evidence.

Yao et al. (2025) conducted a prospective, single-arm trial in 122 individuals diagnosed with NAO (i.e., severe to extreme NOSE score [≥55]). Mean baseline NOSE score was 80.3 (95% CI, 78.1–82.6). The initial study by Yao et al. (2023) documented five total timepoint measurements (i.e., baseline, 3 months, 6 months, 1 year, 2 years) with a primary outcome defined as procedure responders (i.e., individuals with ≥20% improvement in NOSE Scale score or ≥1 severity class improvement from baseline). Unlike previously reported populations in TCRF trials, the authors include and provide analysis for subpopulations such as septal deviation/turbinate, turbinate hypertrophy, nasal polyps, and nasal vestibular stenosis. The latest evidence provides an extended 3-year follow-up of 66 individuals. The primary outcome was change in NOSE score from baseline. The adjusted mean NOSE score at 3 years was 35.1 (95% CI, 27.8–42.3; P<0.001) representing a mean change of −45.3 (95% CI, −54.2 to −36.4; P<0.001). This score improvement is similar to results at previously documented timepoints. Akin to the previous study, medication use was significantly reduced or stopped completely. No serious adverse events (AE) or device-related AEs were reported at the 36-month follow-up. There are some substantial limitations that lessen the strength of this study. The author's aim was to establish durability, but the 3-year extension trial was unplanned and provided a different primary endpoint from the initial study (i.e., “Responders" vs. “Non-responders"). Moreover, there was a considerable loss to follow-up, with over 50% of participants leaving the study. Because of the extended follow-up period, changes in primary outcomes from the original study, and a high attrition rate, it is not possible to draw firm conclusions about the long-term durability of VivAer. Future studies may benefit from conducting a head-to-head trial to better appreciate the influence that VivAer has on NAO populations compared to the standard of care.

Silvers et al. (2024, 2021) and Han et al. (2025, 2022) performed a prospective, multicenter, single-blinded, randomized controlled crossover trial with 77 individuals in the treatment cohort and 41 in the sham control group. Follow-up assessments were scheduled for 3, 12, and 48 months, with an additional extended evaluation planned at the 3-year mark. Individuals had a baseline mean NOSE scale score of 55 or higher (VivAer: 76.7 vs. control: 78.8) and responders were defined as a 20% or more decrease in NOSE score from baseline. At 3 months, the active treatment group had a significantly greater responder rate (88.3% vs. 42.5%; P<0.001) as well as a larger mean change in NOSE score (−42.3 vs. −16.8; P<0.001) compared to the sham cohort. Participants in the treatment group achieved a mean NOSE score of 27.9 (95% CI, 22.3–33.5), indicating substantial symptomatic improvement, whereas majority of the sham control remained severely symptomatic. The authors also performed a post hoc analysis stratified by nasal valve collapse (NVC) diagnosis (i.e., bilateral static, dynamic, and static/dynamic, as well as complex [one nostril static and one nostril dynamic and unilateral static/dynamic]). Baseline NOSE scores were comparable across all groups; however, the bilateral collapse groups demonstrated a significant improvement compared to the sham, highlighting VivAer’s adaptability in addressing diverse NVC subtypes. After the primary endpoint evaluation at 3 months, eligible individuals in the sham control crossed over to the active treatment group. At 12 months, the responder rate was 89.8% (95% CI, 81.7%–94.5%), and the mean NOSE score change continued to improve from baseline (−44.9 [95% CI, −52.1 to −37.7). After 2 years, the responder rate in the treatment cohort (n=73) was sustained (90.4% [95% CI, 81.5% to 95.3%]) from the 3-month timepoint (86.0% [95% CI, 78.2%–91.3%]). They also showed sustained NOSE score treatment effect through 2 years (−41.7 [95% CI, −48.8 to −34.6]) from the 3-month timepoint (adjusted mean, −40.9 [95% CI, −46.9 to −35.0]). The treatment continued to remain beneficial up to the 3-year extended follow-up. The NOSE responder rate was 87%, with an adjusted mean NOSE score of 27.1 (95% CI, 20.4–33.8) and mean difference of −49.5 (95% CI, −56.6 to −42.4; P<0.001). Medication, though not dictated by the trial protocol, was also assessed through 3 years, during which an overall trend in medication reduction or discontinuation was documented. While concomitant medication reflects real-world clinical outcomes, the treatment's effectiveness may be overestimated. Additional limitations include high attrition rate at 3 years (50%) and the lack of comparative long-term outcomes. Despite demonstrated efficacy up to 3 months compared to the sham cohort, the lack of long-term comparison precludes an ability to determine the treatment’s sustained safety and efficacy. Future studies with extended follow-up of the sham cohort are needed to determine the clinically meaningful impact of VivAer in the NAO population.

Kang et al. (2023) conducted a systematic review and meta-analysis of eight studies totaling 451 participants receiving TCRF treatment. The study assessed NOSE scores before and after VivAer at varying time points (i.e., 1, 3, 6, 12, 18, and 24 months). All timepoints demonstrated improved NOSE scores, with months 6, 12, 18, and 24 showing the greatest improvement (mean difference, 6 months: 52.37; 12 months, 50.73; 18 months, 49.85; and 24 months: 56.35). Only the 24-month posttreatment period had a significant improvement from baseline (P=0.0107). Upon further review of individual studies, a major limitation is the use of identical clinical trials for the same timepoint when analyzing change in NOSE scores. This duplication of data skews the sample size for timepoints 6, 12, 18, and 24 months and may reflect inaccurate statistical significance, particularly with the 24-month timepoint. Regardless, without long-term follow-up using a sham or alternative comparator, the efficacy and durability of TCRF cannot be determined based on the reviewed literature.

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Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

15781, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30468, 30520

EXPERIMENTAL/INVESTIGATIONAL

30469

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

SEPTOPLASTY, 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 C44.311 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 D04.39 Carcinoma in situ of skin of other parts of face D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D16.4 Benign neoplasm of bones of skull and face D22.39 Melanocytic nevi of other parts of face D23.39 Other benign neoplasm of skin of other parts 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 J34.8201 Internal nasal valve collapse, static J34.8202 Internal nasal valve collapse, dynamic J34.8211 External nasal valve collapse, static J34.8212 External nasal valve collapse, dynamic 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 Q67.0 Congenital facial asymmetry Q67.1 Congenital compression facies Q67.4 Other congenital deformities of skull, face and jaw S02.2XXA Fracture of nasal bones, initial encounter for closed fracture S02.2XXB Fracture of nasal bones, initial encounter for open fracture
DERMABRASION IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODE:
L71.1 Rhinophyma

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.099f:

03/30/2026

This version of the policy will become effective 03/30/2026.

The following revisions were made to this policy:

Septoplasty

Removed the required documentation of a 4-week conservative medical trial and 75% nasal obstruction threshold. Documentation of an attempted medical trial is still required.

Rhinoplasty/Septorhinoplasty

Removed the required documentation of a 4-week conservative medical trial and 75% nasal obstruction threshold.
Added nasal deformity secondary to congenital deformities as its own criterion
Revised language to indicate that NAOs secondary to trauma, disease, and/or congenital defects are medically necessary only if the nasal obstruction is unresolved, or not expected to resolve, after septoplasty/turbinectomy

The following ICD-10 codes have been removed from this policy:

C44.301, C44.309, D04.30, D22.30, D23.30, J34.3, J34.8200, J34.8210, J34.829, M95.0,Q30.1, Q30.2, Q30.3, Q30.9, Q35.9, Q37.8, Q37.9, S02.2XXD, S02.2XXG, S02.2XXK, S02.2XXS

Revisions From MA11.099e:

10/01/2024

This policy has been identified for a code update, effective 10/01/2024.

The following ICD-10 codes have been added to this policy:

J34.8200 Internal nasal valve collapse, unspecified

J34.8201 Internal nasal valve collapse, static

J34.8202 Internal nasal valve collapse, dynamic

J34.8210 External nasal valve collapse, unspecified

J34.8211 External nasal valve collapse, static

J34.8212 External nasal valve collapse, dynamic

J34.829 Nasal valve collapse, unspecified

Revisions From MA11.099d:

05/01/2024	The policy has been reviewed and reissued to communicate the Company's continuing position on Dermabrasion of Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty. Additional analysis was conducted and added to the policy description for temperature-controlled radiofrequency devices for the treatment of nasal airway obstruction. The coverage position remains unchanged.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
09/05/2023	This version of the policy will become effective 09/25/2023. This policy was updated to communicate the Company's Experimental/Investigational coverage position on the use of low-energy radiofrequency intranasal tissue remodeling for the treatment of nasal airway obstruction.

Revisions From MA11.099c:

01/01/2023

This policy has been identified for the CPT code update, effective 01/01/2023.

The following CPT Procedure Code has been added to this policy as Experimental/Investigational: 30469

Revisions From MA11.099b:

11/16/2022

This policy has been reissued in accordance with the Company's annual review process.

01/03/2022

This version of the policy will become effective 01/03/2022.

The title of this policy was changed to "Dermabrasion for Rhinophyma, Septoplasty, Rhinoplasty, and Septorhinoplasty"

To be consistent with Medicare, dermabrasion was added to the policy, and is considered medically necessary when an individual has a significant impairment of nasal function, such as airway obstruction, caused by rhinophyma.

The following CPT Codes were added to the policy: 15781, 30465, 30468

The following ICD-10 Diagnosis codes were added to the policy as Medically Necessary for Septoplasty, Rhinoplasty and Septorhinoplasty: D04.39, D22.39, D23.39

The following ICD-10 Diagnosis code was added to the policy as Medically Necessary for Dermabrasion: L71.1

The following ICD-10 Diagnosis codes were removed from the policy for Septoplasty, Rhinoplasty and Septorhinoplasty: R04.0, R09.81

Revisions From MA11.099a:

12/02/2020	The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.
10/23/2019	The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.
09/26/2018	The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.
10/10/2017	This version of the policy will become effective 10/10/2017. The policy criteria has been revised regarding trial of conservative medical therapy; conditions added for coverage for septoplasty and rhinoplasty; and required documentation of clinically indicated diagnostic studies to document the deformity and/or obstruction. Claims submitted for septoplasty must include a primary diagnosis code (International Classification of Disease [ICD]-10) to represent septal/nasal deformity. The following ICD-10 CM codes have been added to this policy: C30.0, C41.0, C43.31, C43.39, C44.301, C44.309, C44.311, C44.319, C44.321 C44.329, C44.391, C44.399, C76.0, D03.39, D04.30, D14.0, D16.4, D22.30 D23.30, J34.0, Q30.0, Q35.1, Q35.3, Q35.5, Q35.7, Q35.9, Q36.0, Q36.1, Q36.9 Q37.0, Q37.1, Q37.2, Q37.3, Q37.4, Q37.5, Q37.8, Q37.9, Q67.0, Q67.1, Q67.2 Q67.3, R09.81, S02.2XXA, S02.2XXB, S02.2XXD, S02.2XXG, S02.2XXK, S02.2XXS The following ICD-10 CM codes have been removed from this policy since there are more specific codes for sinusitis: J32.8 Other chronic sinusitis J32.9 Chronic sinusitis, unspecified

Revisions From MA11.099:

12/21/2016	The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.
08/19/2015	The policy has been reviewed and reissued to communicate the Company’s continuing position on Septoplasty, Rhinoplasty, and Septorhinoplasty.
01/01/2015	This is a new policy.

Version Effective Date:

3/30/2026

Version Issued Date: