Rhinoplasty
Cosmetic surgery, or expenses incurred in connection with such surgery, are not covered by Medicare. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.
Rhinoplasty
Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinate. This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures and incision or excision of the overlying skin of the nose.
Nasal surgery, including rhinoplasty, may be either reconstructive or cosmetic in nature. Current CPT codes do not allow distinction of cosmetic or reconstructive procedures by specific codes; therefore, categorization of each procedure is to be distinguished by the presence or absence of specific signs and/or symptoms.
Cosmetic Nasal Surgery
When nasal surgery is performed solely to improve the patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and noncovered under the Medicare program.
Reconstructive Nasal Surgery
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.
Medically Necessary
Photographic documentation (all the following: frontal, lateral and worm’s eye view) of the individual’s condition, and the procedure is performed for correction or repair of any of the following:
- Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment
- Chronic, non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves)
- Secondary to trauma, disease, congenital defect with nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks that has either not resolved after previous septoplasty/turbinectomy, or would not be expected to resolve with septoplasty/turbinectomy alone
Not Medically Necessary
- Solely for the purpose of changing appearance
- As a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met
Septoplasty as Medically Necessary
- Septal deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of conservative medical management lasting at least six weeks
- Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy
- Recurrent epistaxis related to a septal deformity
- Asymptomatic septal deformity that prevents access to other transnasal areas when such access is required to perform medically necessary procedures (e.g., ethmoidectomy)
- Performed in association with cleft lip or cleft palate repair
- Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management and is interfering with the effective use of medically necessary Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder
References
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Rhinoplasty Documentation Checklist
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Section A — Patient Complaints and Physical Signs
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Are there abnormal functions of the nose?
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Is there congenital deformation of the nose?
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For Septoplasty
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Does the patient have any of the following: recurrent sinusitis, epitaxis, asymptomatic septal deformity or obstructed nasal breathing?
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Is this procedure being done to improve the patient’s appearance in the absence of signs and/or symptoms of functional abnormalities? If yes, this is cosmetic and not covered by Medicare.
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For Rhinoplasty
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A brief description of the nose
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For Septoplasty
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A brief description of the septum
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Reconstructive Surgery
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Documented physical findings of the anatomic defect
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Section B — Photographs
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For Photographic Documentation
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Frontal, lateral and worm’s eye views
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For Reconstructive Surgery
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Photographic documentation clearly demonstrating the anatomic defect
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Preoperative exam and notes
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Postoperative notes
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