Rhinoplasty / Nose Job - Medical Necessity Criteria
Criteria for documenting medical necessity of rhinoplasty (nose job)
Contents:
- What is rhinoplasty? How is it different from septoplasty?
- Is rhinoplasty covered by insurance?
- When is rhinoplasty medically necessary?
- Medical necessity criteria for rhinoplasty
- Does Medicare cover rhinoplasty?
- Frequently Asked Questions
- Documentation checklist
- Health plan criteria for rhinoplasty (nose job) and other references
What is rhinoplasty? How is it different from septoplasty?
A rhinoplasty — also known as a “nose job” — is a surgical procedure that changes the shape of the nose. It is often done to improve the appearance of the nose, but it may also be needed to correct breathing problems.
Rhinoplasty is different from septoplasty, which is a surgical procedure that corrects deformities of the nasal septum — the wall that divides the left and right parts of the nose — if the deformity affects airflow and causes difficulty breathing.
Is rhinoplasty covered by insurance?
Rhinoplasty may be covered by insurance if it is medically necessary, that is, if it is being done to address physical functional problems, and not for cosmetic purposes.
When is rhinoplasty medically necessary?
Generally, rhinoplasty is considered medically necessary if it is being done to correct a nasal deformity or nasal obstruction that causes symptoms like difficulty breathing. Different insurance companies and health plans have different medical necessity criteria, but all agree that rhinoplasty done merely to improve appearance (“nose job”) is NOT medically necessary.
Medical necessity criteria for rhinoplasty
Rhinoplasty may be considered medically necessary when it is being performed for any of the following indications:
- To correct or repair a nasal deformity* that directly causes any of the following signs, symptoms, or functional impairments that are not responsive to optimal medical management but are reasonably expected to be resolved by the rhinoplasty:
- inadequate airflow
- chronic or recurrent rhinosinusitis
- feeding difficulties
- To correct chronic nasal obstruction due to trauma, disease, or congenital defect resulting in vestibular stenosis / collapsed internal valves
* The deformity may be caused by:
- congenital cleft lip and/or cleft palate
- destructive inflammatory/infectious diseases
- documented trauma
- nasal fracture
- removal of nasal malignancy
Rhinoplasty is NOT considered medically necessary when it is performed:
- solely for the purpose of improving the patient’s appearance, or
- as the primary treatment for an obstructive sleep disorder.
Does Medicare cover rhinoplasty?
Medicare may consider rhinoplasty medically necessary — and therefore cover it — when the procedure is performed for any of the following indications:
- Nasal deformity due to a cleft lip, cleft palate, or other congenital craniofacial deformity that causes impaired function
- Nasal obstruction due to vestibular stenosis or collapsed internal valves
- Nasal obstruction due to trauma, disease, or congenital defect that was not satisfactorily resolved by — or is not expected to resolve with — septoplasty or turbinectomy alone
- Replacement of nasal tissue lost after tumor ablative surgery
Rhinoplasty is NOT covered by Medicare when it is done:
- Solely to improve the patient’s appearance and/or self-image
- As primary treatment for an obstructive sleep disorder
Frequently Asked Questions
Which insurance covers rhinoplasty?
Most insurance companies — including Aetna, Anthem, Cigna, and UnitedHealthcare — cover rhinoplasty if the patient’s situation meets their medical necessity criteria.
Does BlueShield cover rhinoplasty?
While coverage and medical necessity criteria may vary among BlueShield insurance providers, rhinoplasty is generally covered if it is medically necessary to correct a deformity/obstruction that is causing functional impairment. It is generally NOT covered for the sole purpose of improving an individual’s appearance.
Does Cigna cover rhinoplasty?
Coverage of rhinoplasty may vary across different Cigna plans — check the benefit plan document for coverage details. If it is included among the benefits of the patient’s specific plan, rhinoplasty may be covered if medical necessity criteria are met. Like most other health plans, Cigna does not cover rhinoplasty if it is done only for cosmetic purposes.
Documentation to Submit
These are the things you can prepare documentation of in order to support your statement that rhinoplasty is medically necessary:
Documentation of the relevant condition:
When rhinoplasty is performed as part of a septoplasty:
Documentation of the following history, signs, symptoms, physical examination findings, and/or results of work-up:
Health plan criteria for rhinoplasty (nose job) and other references
- Aetna Criteria for Septoplasty and Rhinoplasty
- Anthem Blue Cross Criteria for Cosmetic and Reconstructive Services of the Head and Neck
- Blue Cross Blue Shield of Tennessee Criteria for Rhinoplasty
- Cigna Criteria for Rhinoplasty, Vestibular Stenosis Repair and Septoplasty
- Medicare local coverage determinations
- Cosmetic and Reconstructive Surgery (First Coast)
- Cosmetic and Reconstructive Surgery (Novitas)
- Cosmetic and Reconstructive Surgery (Palmetto)
- Cosmetic and Reconstructive Surgery (Wisconsin Physicians)
- UnitedHealthcare Criteria for Rhinoplasty and Other Nasal Surgeries