CurrentAlliance HealthPolicy 1A-42

Balloon Ostial Dilation (BOD) — Clinical Coverage Policy

Coverage policy for balloon ostial dilation (balloon sinuplasty) for NC Medicaid beneficiaries, describing eligibility, definitions, general coverage principles, prior authorization and documentation requirements, and procedural context for otolaryngology providers.

Policy Summary

PayerAlliance Health

PolicyBalloon Ostial Dilation (BOD) — Clinical Coverage Policy

Policy CodePolicy 1A-42

Change TypeNo material changes

Effective DateAug 15, 2023

Next Review DateN/A

Key ActionObtain prior approval with otolaryngologist-signed letter of medical necessity and complete supporting documentation demonstrating failed medical therapy and CT confirmation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 weeksCRS duration threshold

4RARS threshold (12 mo)

2 antibiotic trialsMedical therapy trials

Prior approvalAuthorization

4Listed BOD codes

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Coverage Criteria for Balloon Ostial Dilation (BOD)

inv-01: Covered Indications and Preconditions

Covered when ALL of the following are met

General medical necessity: Procedure is individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis; not in excess of the beneficiary's needs

From general criteria (3.1)

Safety and conservatism: Procedure can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide

From general criteria (3.1)

Not for convenience: Procedure is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider

From general criteria (3.1)

Age requirement: Beneficiary is 18 years of age or older unless EPSDT exception applies

Medicaid eligibility/age requirement (Subsection 2.1 and EPSDT note)

Medical therapy prior to BOD for CRS: Documented attempts and failure of medical therapy per policy, including at minimum two different oral antibiotics of two to four weeks duration (culture-directed if possible); additional therapies may include oral or nasal steroids, saline irrigations, decongestants/antihistamines, and treatment of concomitant allergic rhinitis

Medical therapy requirements (1.1.5)

inv-02: Covered Indications

Covered when ALL of the following are met

General medical necessity: Procedure is individualized, specific, consistent with symptoms or confirmed diagnosis, not in excess of the beneficiary's needs; can be safely furnished; no equally effective, more conservative, or less costly treatment is available statewide; not primarily for convenience

From general criteria (3.1)

Specific BOD indications: Stand‑alone BOD (limited to frontal, maxillary, or sphenoid sinuses) for a beneficiary who: (a) has either chronic rhinosinusitis lasting longer than 12 consecutive weeks OR four or more documented episodes of recurrent acute rhinosinusitis (RARS) in 12 calendar months; AND (b) has documented attempts and failure of medical therapy (see 1.1.5); AND (c) CT confirmation that the sinus to be dilated demonstrates at least ONE radiologic finding: bone remodeling/thickening; mucosal thickening >2 mm; complete opacification; OR obstruction of the ostiomeatal complex (note: CT may be nonspecific for RARS; clinical findings required)

Specific criteria (3.2.1)

This policy does not address Functional Endoscopic Sinus Surgery (FESS). FESS is a separate endoscopic surgical procedure for removal of abnormal or obstructive sinus tissue, and coverage determinations for FESS are outside the scope of this BOD policy. Balloon Ostial Dilation (BOD) is discussed independently from FESS in this document.

Balloon Ostial Dilation (BOD) is not covered when performed for the following conditions: nasal polyps or tumors; Samter's Triad (aspirin sensitivity); severe sinusitis secondary to autoimmune or connective tissue disorders (for example, sarcoidosis or Wegener's granulomatosis); severe sinusitis secondary to ciliary dysfunction (for example, cystic fibrosis); contraindication to or inability to tolerate local or topical anesthetic; history of a failed balloon procedure in the sinus to be treated; sinusitis with extensive fungal disease; or significant neo-osteogenesis confirmed by CT.

When Balloon Ostial Dilation (BOD) is performed as an adjunct during Functional Endoscopic Sinus Surgery (FESS), the BOD component is considered integral to the primary FESS procedure and is not separately reimbursable.

BOD is not covered when the beneficiary does not meet the eligibility requirements in Section 2.0, does not meet the clinical criteria in Section 3.0, when the procedure duplicates another provider's service, or when the procedure is experimental, investigational, or part of a clinical trial.

Coding and Procedure Codes

Covered CPT Codes (BOD)CPTCovered

31295	Covered CPT code (sinus balloon dilation)
31296	Covered CPT code (sinus balloon dilation)
31297	Covered CPT code (sinus balloon dilation)
31298	Covered CPT code (sinus balloon dilation)

Covered CPT CodesCPTCovered

31295	CPT Code listed in policy
31296	CPT Code listed in policy
31297	CPT Code listed in policy
31298	CPT Code listed in policy

inv-09: Duration for chronic rhinosinusitis

Duration for chronic rhinosinusitis> 12 consecutive weeks

Context in policyStand‑alone BOD covered when CRS lasts longer than 12 consecutive weeks (see specific criteria).

Medical therapy prerequisiteMust have documented attempts and failure of medical therapy prior to BOD (see Subsection 1.1.5).

inv-10: RARS episode count

RARS episode count>= 4 episodes in 12 calendar months

Definition contextRARS is a subtype of CRS defined as four or more acute rhinosinusitis episodes within a 12‑month period after medical therapy has failed.

Policy requirementStand‑alone BOD covered when beneficiary has ≥4 documented RARS episodes in 12 calendar months plus other criteria.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior approval required when specified

Prior approval is required for Balloon Ostial Dilation (BOD). When prior approval is required, providers must submit the prior approval request through the DHHS Utilization Review Contractor and include all supporting documentation as described in Subsections 5.2.1 and 5.2.2. For beneficiaries under 21, EPSDT does not waive the prior approval requirement — providers must still obtain prior approval when applicable and document medical necessity per EPSDT guidance.

Submit prior approval request to DHHS Utilization Review Contractor (see Subsection 5.2.1).
Include all health records supporting that beneficiary meets specific criteria in Subsection 3.2 (see Subsection 5.2.1.b).
Otolaryngologist must include signed letter of medical necessity, clinical history, sinus documentation, failed medical therapy documentation (see Subsection 1.1.5), and CT findings as specified in Subsection 5.2.2.
EPSDT (beneficiaries <21) still requires prior approval when the procedure is subject to prior approval; include EPSDT rationale in documentation.

Documentation Required

Eligibility verification required

Providers must verify Medicaid eligibility at the time of service for every beneficiary. Services provided when the beneficiary is not enrolled in NC Medicaid or eligibility cannot be verified at the time of service may be denied.

Verify each beneficiary's NC Medicaid eligibility via NCTracks prior to rendering services.
If beneficiary is not enrolled or eligibility is not verified at time of service, claim may be denied.

Denial Risk

General denial triggers

Claims may be denied for several general reasons. Providers should confirm that beneficiaries meet Section 2.0 eligibility, meet Section 3.0 coverage criteria, avoid duplicate services, and ensure services are not experimental or investigational.

Denial triggers include: beneficiary not meeting Section 2.0 eligibility, not meeting Section 3.0 criteria, duplication of another provider's procedure, or service classified as experimental/investigational/clinical trial.
Failure to obtain required prior approval when mandated may also result in denial.

Billing Rule

Coding specificity requirement

Report diagnosis and procedure codes to the highest level of specificity that supports medical necessity. Use the current ICD-10-CM and CPT/HCPCS editions in effect at the time of service.

Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity.
Use current CPT, HCPCS, and UB-04 specifications in effect at time of service.

Documentation Required

Required documentation for prior approval

Submit the prior approval request plus all health records that demonstrate the beneficiary meets the policy-specific criteria. The Otolaryngologist must include specialty-specific documentation as listed below.

Prior approval request and all supporting health records showing criteria in Subsection 3.2 are met (Subsection 5.2.1).
Signed letter of medical necessity by the attending physician and summary of clinical history (Subsection 5.2.2.a).
Documentation of which sinus is involved (Subsection 5.2.2.b).
Documentation of attempted and failed medical therapy (refer to Subsection 1.1.5) for persistent chronic or recurrent acute rhinosinusitis (Subsection 5.2.2.c).
CT scan findings documentation showing one or more specified findings (mucosal thickening >2 mm, complete opacification, bone remodeling/thickening, or obstruction of the ostiomeatal complex) as noted in Subsection 5.2.2.d.

Billing Rule

Procedure coding and special report

Use the most specific CPT/HCPCS code that accurately and completely describes the procedure. If no specific code exists, report the appropriate unlisted procedure code and submit the required special report per CPT/HCPCS instructions.

Covered CPT codes for BOD include 31295, 31296, 31297, 31298 — report per code-specific guidance and limits (see Subsection 5.3 lifetime limit).
If reporting an unlisted procedure, follow CPT/HCPCS instructions for unlisted codes and attach the special report.

Note

Reference documentation

Providers shall comply with NCTracks guides, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for coverage, reimbursement, prior authorization processes, and billing procedures.

Consult NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for operational details and web portal processes.
Follow fee schedules and clinical coverage policies for reimbursement and coverage determinations.

Definitions and Clinical Terms

inv-25: Balloon Ostial Dilation (BOD)

DefinitionProcedure placing and inflating a balloon in the sinus ostium to stretch the opening; also called balloon dilation sinuplasty, balloon catheter sinusotomy, or balloon sinuplasty.

ApproachesTransnasal (through nostrils) or transantral (small entry under the lip); usually performed under general anesthesia but may be local in some cases.

Clinical roleCan be performed as a stand‑alone procedure for chronic rhinosinusitis or adjunctive to FESS; policy focuses on stand‑alone BOD.

inv-26: Functional Endoscopic Sinus Surgery (FESS)

DefinitionEndoscopic removal of abnormal and obstructive sinus tissues via the nostrils using fiber‑optic endoscopes and instruments; largely performed through the nostrils with minimal external signs.

Relation to BODFESS is the traditional invasive surgery; BOD may be adjunctive but this policy does not address FESS reimbursement separately.

Typical featuresUses micro‑telescopes and instruments to remove obstructive tissues with little swelling and mild discomfort.

inv-27: Acute sinusitis

DefinitionRhinosinusitis lasting less than four consecutive weeks.

Classification roleCategorized as acute; distinguishes from subacute and chronic for coverage criteria.

Policy relevanceAcute sinusitis duration threshold helps determine when BOD is not indicated (BOD targeted for chronic or recurrent cases).

inv-28: Subacute sinusitis

DefinitionRhinosinusitis lasting four to twelve consecutive weeks.

Classification roleSubacute category between acute and chronic timeframes; used to differentiate treatment approaches.

Policy relevanceSubacute duration informs chronology but BOD coverage requires chronic (>12 weeks) or recurrent episodes.

inv-29: Chronic rhinosinusitis (CRS)

DefinitionRhinosinusitis lasting longer than 12 consecutive weeks.

Coverage triggerCRS duration >12 weeks is a covered indication for stand‑alone BOD when other criteria are met.

Medical therapy noteDocumentation of failed medical therapy required before BOD for CRS.

inv-30: Recurrent Acute Rhinosinusitis (RARS)

DefinitionSubtype of CRS defined as four or more acute rhinosinusitis episodes within a 12‑month period after medical therapy has failed.

Coverage linkage≥4 documented RARS episodes in 12 months is an alternative covered indication for stand‑alone BOD when combined with failed medical therapy and CT findings.

CT noteCT scans can be nonspecific for diagnosing RARS; clinical findings are required to support intervention.

inv-31: Chronic rhinosinusitis / RARS criteria

CRS criterionSymptoms lasting >12 consecutive weeks (chronic rhinosinusitis).

RARS criterionFour or more documented acute rhinosinusitis episodes in 12 calendar months (RARS).

Combined policy requirementStand‑alone BOD covered when either CRS (>12 weeks) OR RARS (≥4 episodes/12 months) is present, plus failed medical therapy and qualifying CT findings.

inv-32: Supporting CT findings

Required CT findings (one of the following)bone remodeling/thickening; mucosal thickening >2 mm; complete opacification; or obstruction of the ostiomeatal complex.

Diagnostic caveatCT scans can be nonspecific for RARS; therefore clinical findings are required to support surgical intervention.

Submission requirementOTL must include documentation of CT finding(s) with prior approval request per Subsection 5.2.2.

inv-33: BOD CPT codes

Listed CPT codes31295, 31296, 31297, 31298

Billing instructionReport the most specific CPT/HCPCS code that accurately describes the procedure; if no specific code exists, use appropriate unlisted code and follow special report instructions.

Payment limitation noteWith prior approval, each listed CPT code is payable one time per sinus per beneficiary lifetime (see Subsection 5.3).

OpenPayer

Balloon Ostial Dilation (BOD) — Clinical Coverage Policy

Coverage Criteria for Balloon Ostial Dilation (BOD)

Coding and Procedure Codes

Provider Requirements, Prior Authorization, and Documentation

Definitions and Clinical Terms

Background and Clinical Context

Policy Revision History