CurrentAetnaPolicy 0694

Evaluation of Sinusitis

Defines Aetna's coverage stance and evaluation considerations for diagnostic tests and biomarkers used in the assessment of acute and chronic sinusitis for members and providers.

Policy Summary

PayerAetna

PolicyEvaluation of Sinusitis

Policy CodePolicy 0694

Change TypeNo material changes

Effective DateDec 7, 2004

Next Review DateJul 25, 2024

Key ActionDo not submit claims for paranasal sinus ultrasound (CPT 76536, HCPCS S9024) for sinusitis indications as they are listed as not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30MU.S. individuals affected annually

90%Physician visit rate

76536,S9024Ultrasound codes not covered

J01.*,J32.*,R43.0ICD-10 codes referenced

SeveralTests labeled investigational

52References listed

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Coverage criteria for diagnostic testing in sinusitis

Imaging and diagnostic testing for sinusitis

Covered or not covered based on clinical indications and current evidence; apply when ALL conditions below are considered:

Primary stance: Clinical diagnosis is the primary basis for diagnosing acute and chronic sinusitis; imaging is confirmatory and CT is the preferred imaging modality when imaging is indicated (e.g., persistent symptoms after appropriate therapy, pre-operative evaluation, or suspected complications).

Supported by ACR and guideline citations in the policy.

Tests considered experimental or investigational (not covered for routine evaluation): Detection of IgG4-positive plasma cells in nasal/paranasal tissue; examination of tissue eosinophilia for prediction of disease severity or olfactory loss; examination of EGFR ligands (e.g., epiregulin) and matrix metalloproteinases; microarray DNA testing or RNA-seq approaches; type 2 cytokine panels (IL-4, IL-5, IL-13); periostin (tissue or serum) measurement; TAS2R38 genotyping and other taste receptor testing; para-nasal sinus ultrasound.

Listed explicitly as experimental and investigational due to insufficient evidence.

Ultrasound coding and coverage note: Paranasal sinus ultrasound (CPT 76536; HCPCS S9024) is listed as not covered for the indications in this policy (evaluation of acute or chronic sinusitis) and may be denied for those indications.

See CPT/HCPCS codes not covered.

Coverage-relevant evidence summary

Summary of evidence-based conclusions relevant to coverage (informational):

General evidence sufficiency: Available biomarker and molecular tests (serum IgE stratification, tissue eosinophilia assessments, EGFR ligands/MMP-1, microarray/RNA-seq findings, periostin levels, taste receptor genotyping/phenotyping) are preliminary; studies are generally small, heterogeneous, and recommend larger, prospective validation prior to routine clinical implementation.

Multiple excerpts state need for validation and larger studies.

Specific findings with potential clinical relevance: Reportable associations include: higher tissue eosinophil counts in CRSwNP that correlate with worse olfactory function (Hauser et al., prospective study); elevated periostin (POSTN mRNA/protein) in CRSwNP versus CRSsNP or controls (systematic review); and mixed data on TAS2R38 genotype/phenotype—some studies associate the AVI/AVI ‘non-taster’ haplotype with increased surgery rates or poorer post-op improvement, while other studies find no consistent genotype–outcome relationship.

Findings are associative and inconsistent across studies.

Immunodeficiency testing in recurrent acute rhinosinusitis (RARS): Consideration for immunologic evaluation (e.g., quantitative immunoglobulins, post-vaccination antibody titers, IgG subclass testing) may be appropriate after recurrent infections or diagnosis of RARS; however, consensus on timing, target populations, and specific methods is limited.

The policy lists several molecular assays and biomarkers (for example, detection of IgG4-positive plasma cells, tissue eosinophilia, type 2 cytokines, microarray/RNA sequencing approaches, TAS2R38 genotyping, and periostin tissue/serum measurement) as experimental and investigational because evidence is insufficient to support routine clinical use. These items are explicitly identified in the policy's experimental/investigational list and are not supported as standard diagnostic tests for evaluation of chronic rhinosinusitis or sinusitis.

The document presents molecular assays — including whole-transcriptome analyses, periostin measurement, and taste receptor genotyping/phenotyping — as research-phase findings. For example, RNA-seq and validation studies identified candidate transcripts (e.g., TRPV3) needing further functional study (RNA-seq example), a periostin systematic review found elevated POSTN expression in CRSwNP but called for prospective validation, and taste receptor reviews reported mixed, inconclusive associations with clinical outcomes. Collectively these excerpts frame molecular tests as preliminary and appropriate for investigational or research use rather than routine clinical decision-making.

This Clinical Policy Bulletin is intended to assist in administering plan benefits and provides a partial, general description of those benefits. It does not constitute a contract, an offer of coverage, or medical advice. Participating providers remain responsible for treatment decisions and must follow applicable plan benefit rules; the bulletin may be updated and is subject to change.

Use of paranasal sinus ultrasound (CPT 76536; HCPCS S9024) for evaluation of acute or chronic sinusitis is not supported for the indications listed in this policy and is identified as not covered. The background discussion also notes that paranasal ultrasound has limited sensitivity and specificity and is not recommended as a routine diagnostic modality for sinusitis.

The policy characterizes the listed molecular and biomarker tests (for example, IgG4 detection, tissue eosinophilia, EGFR ligands/MMPs, microarray/RNA-seq, periostin, and taste receptor/TAS2R38 testing) as preliminary and requiring further validation. The policy states these approaches are experimental/investigational due to insufficient evidence and recommends that prospective, well-designed studies are needed before these tests are incorporated into routine clinical practice.

Relevant billing and diagnosis codes

CPT codes not covered for listed indicationsCPTNot Covered

76536

Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation

HCPCS codes not covered for listed indicationsHCPCSNot Covered

S9024

Paranasal sinus ultrasound

ICD-10 codes referenced in policyICD-10

J01.00-J01.91	Acute sinusitis
J32.0-J32.9	Chronic sinusitis
R43.0	Anosmia [CRS-associated olfactory loss]

What providers must know and do

Prior Authorization

Prior Authorization Note — Sinus Ultrasound

Some Aetna plans or administrative requirements may require prior authorization for imaging or diagnostic procedures when applicable. Check the member's plan prior authorization rules before ordering procedures related to sinus evaluation.

Prior authorization requirements vary by plan — submit prior auth when the member's benefit or administrative rules require it.
When in doubt, verify prior authorization via the payer portal or contact provider services.

Denial Risk

Ultrasound Not Covered for Sinusitis Evaluation

Ultrasound of the paranasal sinuses is considered not covered for the evaluation of sinusitis for the indications described in this bulletin. Claims for CPT 76536 and HCPCS S9024 for acute or chronic sinusitis or CRS-associated olfactory loss are not covered.

CPT 76536 — Ultrasound, soft tissues of head and neck — not covered for sinusitis evaluation.

Background and clinical context

Sinusitis is a common disorder that causes nasal congestion, purulent nasal discharge, facial pain or pressure, and other sinonasal symptoms; it affects over 30 million people annually in the United States. Clinical diagnosis and patient history are emphasized as the basis for management. Imaging is confirmatory when indicated: CT is the preferred imaging modality for persistent, complicated, or pre-operative cases, while plain radiographs and paranasal sinus ultrasound have limited utility because of low sensitivity, low specificity, and operator dependence.

Key definitions and terms

Gold standard — sinus aspiration and culture defined as recovery of bacteria in high density

DefinitionRecovery of bacteria in high density from the cavity of a paranasal sinus (sinus aspiration and culture) is the gold standard for diagnosis of acute bacterial sinusitis.

Clinical noteSinus aspiration is invasive, time-consuming, potentially painful, and should only be performed by an otolaryngologist; not feasible for routine primary care diagnosis.

Use limitationSinus aspiration is not recommended as a routine diagnostic method in children due to invasiveness and practical constraints.

Appropriateness of paranasal ultrasound — low sensitivity/specificity and operator dependence

Summary statementParanasal sinus ultrasound has generally low sensitivity and specificity and lacks sufficient accuracy for routine diagnostic use in sinusitis.

Operator dependence

Policy Summary

PayerAetna

PolicyEvaluation of Sinusitis

Policy CodePolicy 0694

Change TypeNo material changes

Effective DateDec 7, 2004

Next Review DateJul 25, 2024

Key ActionDo not submit claims for paranasal sinus ultrasound (CPT 76536, HCPCS S9024) for sinusitis indications as they are listed as not covered.

SourceLink

On This Page

Recommendations vary among small studies and reviews.

HCPCS S9024 — Paranasal sinus ultrasound — not covered for sinusitis evaluation.

ICD-10 codes J01.00-J01.91, J32.0-J32.9, R43.0 referenced in CPB as related diagnoses.

Note

Immunodeficiency Testing Uncertainty

There is limited and inconsistent evidence on the timing and methodology for immunodeficiency (primary immune-deficiency disorder) testing in patients with recurrent acute rhinosinusitis (RARS). Providers should consider current clinical guidance and individual patient context when deciding on immunodeficiency workup.

No clear consensus or standardized guideline for when to perform PIDD testing in RARS.
Commonly reported approaches include general immunologic screening, quantitative immunoglobulins, post-vaccination antibody titers, and IgG subclass testing; timing often recommended after recurrent infections or diagnosis but varies across studies.

Documentation Required

Diagnostic Approach Documentation

The diagnosis of acute and chronic sinusitis is primarily clinical. Document the patient's history, symptom duration and severity, physical exam findings, prior medical therapy, and rationale for any imaging or additional diagnostic testing. CT is the preferred imaging modality when imaging is indicated (e.g., persistent symptoms after medical therapy or pre-operative evaluation).

Document symptom duration and severity, response to medical therapy, and reason imaging is being requested.
If imaging is needed after failure of medical therapy or for surgical planning, coronal CT of the sinuses is preferred.
Avoid imaging (including ultrasound) if full clinical resolution occurs after appropriate therapy.

Documentation Required

Justify Biomarker/Molecular Testing

When considering biomarker or molecular testing (e.g., IgE, tissue eosinophilia assessment, type 2 cytokines, periostin, genetic testing), document the clinical rationale and how results will influence management. Many biomarkers remain investigational and require validation before routine clinical use.

Document indication for testing, anticipated impact on treatment decisions (e.g., guiding biologic therapy, surgical planning), and prior/concurrent therapies.
Be aware that tests such as IgG4 detection, tissue eosinophilia for certain predictions, type 2 cytokine panels, periostin, microarray DNA testing, and certain genotyping approaches are considered experimental/investigational per this CPB.

Documentation Required

Provider Documentation Reminder

Providers must document the clinical rationale for diagnostic and therapeutic decisions in the member record. The Clinical Policy Bulletin is a partial description of plan benefits — document member-specific clinical findings and justification for services to support coverage determinations.

Include history, exam findings, prior treatments and responses, and how proposed testing or procedures will affect management.
Retain documentation to substantiate medical necessity for imaging, laboratory, or procedural services.

Documentation Required

Imaging After Medical Therapy

Imaging for sinusitis should generally be performed only after an adequate trial of medical therapy when symptoms persist or complications are suspected, or when imaging is required for surgical planning. Routine imaging is not indicated for uncomplicated acute sinusitis that resolves with treatment.

Consider coronal sinus CT for patients with persistent symptoms after appropriate medical therapy (e.g., >10 days or failing therapy) or for pre-operative evaluation.
Avoid routine radiography or ultrasound for uncomplicated cases that resolve clinically.

Ultrasound accuracy is highly examiner-dependent, contributing to variability in results across studies.

Guideline stanceThe ACR assigned an appropriateness rating of 1–2 (least appropriate) for paranasal sinus ultrasound and does not recommend it for routine evaluation.

Potential niche useUltrasound may have limited applicability in specific circumstances (e.g., pregnant patients or estimating retained secretions) but is not generally preferred over CT.

CRSwNP — chronic rhinosinusitis with nasal polyps definition and associations

DefinitionChronic rhinosinusitis with nasal polyps (CRSwNP): a form of CRS characterized by presence of nasal polyps and higher tissue eosinophilia and type 2 inflammation.

Associated findingCRSwNP is associated with higher mean tissue eosinophil counts compared with CRSsNP (reported example: 71.6 vs 28.1 eosinophils/HPF in one cohort).

Clinical impactHigher tissue eosinophilia in CRSwNP correlates with worse olfactory function independent of overall disease severity.

RARS — recurrent acute rhinosinusitis definition and evaluation note

DefinitionRecurrent acute rhinosinusitis (RARS): repeated discrete episodes of acute rhinosinusitis occurring over time.

Evaluation noteConsideration of immunologic evaluation (general screening, quantitative immunoglobulins, post-vaccination antibody titers, IgG subclass testing) is commonly recommended following recurrent infections or diagnosis of RARS.

Evidence limitationThere is no consensus on timing, target populations, or specific testing methodology for primary immunodeficiency evaluation in RARS; recommendations and definitions vary across studies.

Clinical Policy Bulletin — definition and disclaimer about coverage and medical advice

PurposeThis Clinical Policy Bulletin (CPB) provides Aetna's guidance to assist in administering plan benefits related to evaluation of sinusitis.

Not coverage guaranteeThe CPB does not constitute an offer of coverage or medical advice; coverage determinations depend on individual plan provisions and benefit documents.

Provider responsibilityProviders remain responsible for treatment decisions and should follow participating plan rules and document clinical rationale for diagnostic testing.