TRANSMITTAL #:  124

DATE:  06/30/2010

TRICARE CHANGE #:  N/A

 

CHAMPVA POLICY MANUAL

 

CHAPTER: 2

SECTION: 7.8

TITLE: RHINOPLASTY

 

AUTHORITY: 38 CFR 17.270(a) and 17.272(a)

 

RELATED AUTHORITY: 32 CFR 199.4(c)(2) and (e)(8)

 

 

I. EFFECTIVE DATE(S)

October 22, 1985

II. PROCEDURE CODE(S)

CPT Codes:  30400-30462; 30630

III. DESCRIPTION(S)

A. A plastic surgery operation on the nose, either reconstructive, restorative or cosmetic.

IV. POLICY

A. Rhinoplasties are covered under the following circumstances:

1. Correction of a congenital anomaly, that is, a condition that exists from birth and is a significant deviation or departure from the norm and is other than a common racial or ethnic feature, such as a cleft lip/cleft palate.

2. Required due to accidental injury which resulted in obstruction of breathing.

3. The attending physician documents that the rhinoplasty was an integral part of an internal procedure to restore function.

B. Rhinoplasties are subject to clinical review.

C. Claims for reimbursement of a rhinoplasty must include:

1. Medical documentation that reflects history of recent trauma, the dates of injury, dates of related surgeries, degree of nasal obstruction, and other symptoms of breathing obstruction such as nasal stuffiness, dryness, mouth breathing, etc.

2. Operative report.

V. EXCLUSION(S)

A. Surgery for psychological reasons.

B. Cosmetic surgery that is performed to primarily improve physical appearance without correcting or materially improving a bodily function such as:

1. Altar tip cartilage repair.

2. Dorsal hump removal.

3. Shortening of the nasal septum.

4. Narrowing of the bony pyramid.

5. Nasal tip reconstruction.

6. Repair of unrecognized trauma, that is, trauma which is not related specifically to time or event.

7. Saddle nose deformity.

*END OF POLICY*