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DESCRIPTIONRhinoplasty is a surgical procedure done to change the form and/or function of the nose to correct nasal deformity. Correction of a nasal deformity by rhinoplasty is done to improve the airway, provide balance to the face or to improve appearance.
POLICYRhinoplasty done for the sole purpose to improve facial balance and/or appearance without documented prior trauma or other obstruction is considered cosmetic and is not medically necessary.
Rhinoplasty done to correct airway deformity caused by a congenital defect that impairs normal function (e.g., air flow for adequate breathing) or as a result of nasal/facial injuries sustained from a traumatic event is considered medically necessary. Examples would include cleft lip/palate or severe burns. Photographs, as part of the normal history and physical exam, should be kept in the patient medical records.
POLICY GUIDELINESNote that photography is not separately billable.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY2/1998: Approved by the Medical Policy Advisory Committee (MPAC)
4/9/2001: Policy revised; Description, Policy, Managed Care Requirements deleted
5/2001: Revisions approved by MPAC; sources updated
1/23/2002: Prior authorization deleted
5/2/2002: Type of Service and Place of Service deleted
5/9/2002: Code Reference section completed
2/13/2004: Code Reference section updated, ICD-9 procedure code 21.81, 21.82, 21.83, 21.88, 21.89 deleted, ICD-9 diagnosis code range 749.00-749.25, 873.20-873.39 listed separately
12/31/2008: Policy reviewed, no changes.
03/27/2014: Policy reviewed; no changes to policy statement.
08/24/2015: Code Reference section updated to add ICD-10 codes and to remove the Not Medically Necessary Codes table and ICD-9 diagnosis code V50.1.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of North Carolina
AETNA U.S. Healthcare ®
Alliance Blue Cross Blue Shield
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the"Policy" section of this document.