OHIP & Coverage
What OHIP pays for, and what it doesn't.
Endoscopic sinus surgery, nasal polyp surgery and septoplasty are insured under OHIP when medically necessary — OHIP pays the surgeon and the hospital. Surgery to change the appearance of the nose is not insured by OHIP. Where one operation addresses both breathing and appearance, the insured and uninsured parts are identified separately, in writing, before anything is decided.
Written and reviewed by Dr. Justin Khetani, MD, FRCSC, Otolaryngology–Head and Neck Surgery · Last reviewed
The Short Version
The short version
Nose and sinus surgery is insured under OHIP when medically necessary — OHIP pays the surgeon and the hospital. Surgery to change the appearance of the nose is not insured by OHIP. Where one operation addresses both breathing and appearance, the insured and uninsured parts are identified separately, in writing, before anything is decided.
01 / 07
Procedure by Procedure
Insured, pre-approved, or private.
"Medically necessary" is the Health Insurance Act's own test: the procedure treats a medical problem, is listed in Ontario's Schedule of Benefits, and is not done solely to change appearance. What that means for each procedure is set out below; what it means for you is established at consultation.
| Procedure | Insured when medically necessary? | Notes |
|---|---|---|
| Endoscopic sinus surgery | Yes | For chronic sinus disease that has not settled with medical therapy. About the operation. |
| Nasal polyp surgery | Yes | Polyp removal with opening of the sinuses. About nasal polyps. |
| Septoplasty | Yes | For nasal obstruction from a deviated septum. About the operation. |
| Turbinate reduction | Yes | Alone or with septoplasty or sinus surgery. |
| Septorhinoplasty / functional rhinoplasty | Yes — needs written Ministry of Health approval. | Where the Ministry approves it, no additional charge is made for the operation. |
| Cosmetic rhinoplasty | No | Fees are quoted in writing after assessment. How rhinoplasty fees work. |
| Revision rhinoplasty | Only if the original operation was insured and the revision falls inside the recognised period | Acute complications of any operation are insured. How the revision rule works. |
| Office nasal endoscopy | Yes | Part of an insured specialist assessment. |
| CT of the sinuses, ordered for a medical reason | Yes | Performed at the hospital. |
| Allergy skin testing | Yes, with an annual limit | Ordered where allergy is suspected of driving the sinus disease. |
| Biologic medicines for nasal polyps | Not a surgical fee — funded through drug plans | See "Medicines for nasal polyps" below. |
| Non-surgical facial treatments | No | The non-surgical page explains what remains available. |
General education, not a coverage decision. Whether a procedure is medically necessary in your case is a clinical judgement made at consultation, and OHIP's rules are the Ministry of Health's, not the practice's.
02 / 07
What OHIP Pays
The surgeon's fee and the hospital's costs.
For insured surgery in a public hospital, OHIP pays the surgeon and the hospital. You do not receive a bill for the operation, the anesthesia or the hospital stay.
The hospital may charge for incidental items that OHIP does not insure — transport home, some supplies or equipment, a private room where you request one — and for medications you take home after discharge. The hospital tells you about any such charge before it applies.
03 / 07
Getting Seen
Do I need a referral?
An OHIP-insured assessment begins with a referral from your physician or nurse practitioner. Referrals are faxed to (905) 639-2253, and the office contacts you once yours is received.
A cosmetic consultation is different: no referral is needed, and you can request one directly through the office at (905) 639-2244.
04 / 07
Combined Operations
When one operation does two jobs.
Some operations straighten the airway and change the nose's shape at the same time. Where one operation addresses both breathing and appearance, the insured and uninsured parts are identified separately, in writing, before anything is decided. The rhinoplasty part needs written approval from the Ministry of Health; where the Ministry approves it, no additional charge is made for the operation.
The surgeon applies for that approval on the Ministry's own form after your assessment, and an approval is valid for one year. If the Ministry approves only the septoplasty component, the cosmetic part remains private and is quoted in writing like any other. Pre-approval, step by step · how this works on the rhinoplasty page.
05 / 07
Medicines for Nasal Polyps
Drugs are funded differently from surgery.
Biologic medicines are funded through provincial or private drug plans rather than as a surgical fee; the office prepares the application after assessment. For eligible patients that route is the Ontario Drug Benefit's Exceptional Access Program; for others it is a private or workplace drug plan. Which medicines suit you, and whether you meet the criteria, is part of the consultation. More on the nasal polyps page.
06 / 07
Fees for Care That Isn't Insured
In writing, before you decide.
For cosmetic surgery and other uninsured care, fees are quoted in writing after assessment. You receive the quotation before you decide anything, an itemised invoice is available on request, and fees are set with reference to the Ontario Medical Association's guide. The starting figure and what a quotation includes are on the rhinoplasty page.
A fee never buys a shorter wait
Priority is set by clinical urgency and hospital scheduling. Paying a fee never changes a person's place in line for insured care. That includes the paid cosmetic consultation: it neither speeds up nor slows down an insured assessment or operation. How waits actually work.
07 / 07
Common Questions
Coverage, answered plainly.
Endoscopic sinus surgery is insured under OHIP when medically necessary — OHIP pays the surgeon and the hospital. An OHIP-insured assessment begins with a referral from your physician or nurse practitioner.
Septoplasty is insured under OHIP when medically necessary — OHIP pays the surgeon and the hospital. Changing the nose's appearance at the same time is a separate question: see the combined-operations section above.
Surgery to change the appearance of the nose is not insured by OHIP. Fees are quoted in writing after assessment. Where one operation addresses both breathing and appearance, the insured and uninsured parts are identified separately, in writing, before anything is decided.
The rhinoplasty part of a combined operation needs written Ministry of Health approval. The surgeon applies on the Ministry's form after your assessment, an approval is valid for one year, and where the Ministry approves it, no additional charge is made for the operation.
An OHIP-insured assessment begins with a referral from your physician or nurse practitioner, faxed to (905) 639-2253. A cosmetic consultation does not need one; you can request it directly through the office.
Not for insured surgery itself: OHIP pays the surgeon and the hospital. The hospital may charge for incidental items such as transport, some supplies or equipment, and for medications you take home; it tells you about any such charge before it applies.
The rules summarised here are the Ministry of Health's: Ontario's Schedule of Benefits (opens in a new tab) lists what OHIP insures, and the Ministry's prior-approval form (0691-84) (opens in a new tab) is how a combined operation is approved. These are references, not advice; your situation is assessed individually.
Assessment first. Then the options are yours.
An OHIP-insured assessment begins with a referral from your physician or nurse practitioner. The office contacts you once it is received.