BlueCross BlueShield of Minnesota Medical Policy

 
 

Medical Policy:
IV-73-008
Topic:
Rhinoplasty
Section:
Surgery
Effective Date:
April 27, 2020
Issued Date:
April 27, 2020
Last Revision Date:
April 2020
Annual Review:
April 2020
 
 

Rhinoplasty is a surgical procedure to repair or reshape the nose.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

I.  Rhinoplasty may be considered MEDICALLY NECESSARY AND APPROPRIATE when ANY of the following criteria are met:

  • A structural abnormality displaces the nasal structure, resulting in fixed, medically significant airway obstruction that medical therapy has failed to correct; OR
  • Performed on an eligible dependent child who has a congenital disease or anomaly that has caused a functional defect (e.g. cleft palate) as determined by the attending physician; OR
  • Incidental to or following another surgery that was needed because of injury, sickness or disease of that part of the body.

II.  Rhinoplasty is considered COSMETIC for all other indications.

30400 30410 30430 30435 30450 30460 30462





Denial Statements

No additional statements.



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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies.

Medicaid products and some self-insured plans may have additional policies and prior authorization requirements. As applicable, review the provisions relating to a specific coverage determination, including exclusions and limitations. Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.


For Medicare NCD and/or Medicare LCD, please consult CMS or National Government Services websites.


Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and /or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.