Clinical UM Guideline
|Guideline #:||CG-SURG-18||Current Effective Date:||06/28/2016|
|Status:||Reviewed||Last Review Date:||05/05/2016|
This document addresses indications for septoplasty. This document may also be used to review the septoplasty component of procedures which combine both rhinoplasty and septoplasty (that is, rhinoseptoplasty). Medically necessary criteria for the rhinoplasty component of the combined procedure and relevant coding instructions can be found in ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck.
Note: Please see the following related documents for additional information:
Nasal septoplasty is considered medically necessary for the following conditions when an appropriate and reasonable trial of conservative management (which might include use of topical nasal corticosteroids, decongestants, antibiotics, allergy evaluation and therapy, etc.) has failed.
Not Medically Necessary:
Septoplasty is considered not medically necessary for any of the following:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|30520||Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft|
|30620||Septal or other intranasal dermatoplasty (does not include obtaining graft)|
|09BM0ZZ||Excision of nasal septum, open approach|
|09BM3ZZ||Excision of nasal septum, percutaneous approach|
|09BM4ZZ||Excision of nasal septum, percutaneous endoscopic approach|
|09SM0ZZ||Reposition nasal septum, open approach|
|09SM4ZZ||Reposition nasal septum, percutaneous endoscopic approach|
|09TM0ZZ||Resection of nasal septum, open approach|
|09TM4ZZ||Resection of nasal septum, percutaneous endoscopic approach|
|J34.0||Abscess, furuncle and carbuncle of nose|
|J34.1||Cyst and mucocele of nose and nasal sinus|
|J34.2||Deviated nasal septum|
|J34.81-J34.89||Other specified disorders of nose and nasal sinuses|
|Q67.4||Other congenital deformities of skull, face and jaw|
|S02.2XXA-S02.2XXS||Fracture of nasal bones|
Septoplasty is a surgical procedure performed to correct airway obstruction related to the nasal septum. These obstructions can be caused by structural deformity, disease or trauma.
Deviation of the nasal septum is a common cause for nasal obstruction. Septal deviation occurs when the septum, which divides the two sides of the nasal cavity, is displaced from a straight vertical alignment causing blockage of airflow through one or both sides of the nose. The change in airflow can contribute to mucosal drying leading to epistaxis and sinusitis. Frequently these complications respond to medical treatment such as antibiotic and steroid therapy. When medical management is not successful, a septoplasty is considered. This surgical procedure, usually performed under local or general anesthesia, corrects nasal septum defects or deformities by alteration, splinting, or partial removal of obstructing structures. Septoplasty is usually done to improve breathing, but it also may be performed to assist in the management of polyps, tumors or epistaxis.
Moore and Eccles (2011) reported on a review of 14 articles in which nasal airflow was measured before and after septoplasty due to nasal obstruction because of septal deviation. The articles were limited to those with surgery on the nasal septum (including septoplasty, submucous resection and septal deviation corrective surgery) and articles with different forms of objective measurement of nasal airflow including rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow. The 14 articles included 536 participants and all showed "objective evidence that septal surgery improves nasal patency."
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
|Reviewed||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description/Scope, Background/Overview, and Reference sections. Removed ICD-9 codes from Coding section.|
|Reviewed||05/15/2014||MPTAC review. Updated Description and Coding sections.|
|Reviewed||08/08/2013||MPTAC review. Updated References.|
|Revised||08/09/2012||MPTAC review. Updated Discussion/General Information and References. Clarification to Clinical Indications.|
|Reviewed||11/17/2011||MPTAC review. Updated Discussion/General Information and References.|
|Reviewed||11/18/2010||MPTAC review. Updated References.|
|Reviewed||02/25/2010||MPTAC review. Updated References.|
|Reviewed||02/26/2009||MPTAC review. Updated References and Web Sites. Removed Place of Service.|
|Reviewed||02/21/2008||MPTAC review. References and Coding updated.|
|Reviewed||03/08/2007||MPTAC review. References and Coding updated.|
|New||03/23/2006||MPTAC initial document development.|