Surgical Treatment of Sinus Disease
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Policy governing coverage and clinical guidance for surgical treatments of sinus disease (including functional endoscopic sinus surgery, implants, and related procedures) for Blue Cross Blue Shield of North Carolina members.
No material clinical or coverage changes in this revision.
Coverage criteria and policy-level rules
Coverage highlights and notable device/technique rules
When Covered / When Not Covered sections and policy-level billing clarifications have changed over time; key highlights and device/technique rules from the implementation history are:
See policy guidelines for definitions of optimal medical therapy and specific clinical indications
Mometasone furoate sinus implant (Sinuva and similar) — covered use
- Individual is ≥ 18 years of age.age >= 18
Added to When Covered section per 9/29/23 update
- Ethmoid or frontal sinus surgery is planned.
Policy history: bullet updated to specify ethmoid or frontal sinus
Historical additions and deletions of J3490, C9122, S1090/S1091/J7402 reflect evolving coding and coverage stance.
Added 6/29/12; reiterated in When Not Covered section
Implantable sinus stents and spacers have a variable coverage history in this policy. Early updates documented that these devices — used for postoperative management after endoscopic sinus surgery — were explicitly discussed and at one point designated as investigational for postoperative use, with investigational services not covered by BCBSNC. Over successive updates the policy added device‑specific language (for example, the Propel™ sinus implant) and defined medical necessity criteria tied to the surgical setting and target sinus cavities. These historical entries indicate the policy has evolved from a general investigational stance to device‑specific coverage rules tied to procedure and anatomic site.
Policy language added in 2012 established specific limits for the Propel™ sinus implant: it may be considered medically necessary only when both criteria are met — implanted at the time of an approved functional endoscopic sinus surgery (FESS) and implanted in the ethmoid sinus only. The policy also states that use of the Propel implant is considered not medically necessary if it is inserted in any surgical setting other than FESS or placed in sinus cavities other than the ethmoid.
Billing, codes, and age-related coding notes
| 31237 | CPT code added back to Billing/Coding section (document notes) |
| 31299 | CPT code added to Billing/Coding section (document notes) |
| 31241 | CPT code added to Billing/Coding section (document notes) |
| 31253 | CPT code added to Billing/Coding section (document notes) |
| 31257 | CPT code added to Billing/Coding section (document notes) |
| 31259 | CPT code added to Billing/Coding section (document notes) |
| 31298 | CPT code added to Billing/Coding section (document notes) |
| 31295 | Balloon sinuplasty CPT code (not separately reimbursable when performed with FESS in same sinus cavity) |
| 31296 | Balloon sinuplasty CPT code (not separately reimbursable when performed with FESS in same sinus cavity) |
| 31297 | Balloon sinuplasty CPT code (not separately reimbursable when performed with FESS in same sinus cavity) |
Provider billing guidance and required documentation
Balloon sinuplasty incidental when performed with FESS in same cavity
When balloon sinuplasty CPT codes 31295–31297 are performed in conjunction with functional endoscopic sinus surgery (FESS) within the same sinus cavity, treat the balloon sinuplasty as incidental to the major FESS service and do not bill or expect separate reimbursement for those codes.
Confirm billing/auth details and related policy alignment
Ensure prior authorization and billing reflect the policy’s specific device and procedure rules (see related billing/coding entries and code-specific notes) to avoid denials or incorrect payments.
- Confirm applicable CPT/HCPCS codes are current in the billing claim (policy history documents multiple code additions and deletions).
- Refer to related Balloon Ostial Dilation policy when submitting BOD requests per 7/14/20 update.
Obtain and document CT and/or nasal endoscopy after optimal medical therapy
Document coronal CT scan and/or nasal endoscopy results after a trial of optimal medical therapy for chronic rhinosinusitis, and obtain CT and/or nasal endoscopy during an acute episode for recurrent acute rhinosinusitis to demonstrate sinus pathology amenable to surgery.
- For chronic rhinosinusitis: coronal CT and/or nasal endoscopy following optimal medical therapy showing persistent sinus pathology.
- For recurrent acute rhinosinusitis: CT and/or nasal endoscopy during the acute episode to document treatable sinus pathology.
Propel implant insertion outside approved FESS/ethmoid setting is not medically necessary
Do not use the Propel sinus implant outside of the approved FESS setting or outside the ethmoid sinus; insertion of Propel in other surgical settings or sinus cavities has been identified as not medically necessary and may trigger non-coverage.
- Policy language: “Use of the Propel sinus implant is considered not medically necessary if inserted at any surgical setting other than the FESS procedure, or for any sinus cavities other than the ethmoid.”
Definitions and key terms
Clinical background and evidence base
The policy record cites specialty panel reviews and literature updates informing coverage decisions. References and guideline material were added repeatedly (noted in 2012, 2013 and 2014 updates) and the Description section was expanded in 2014 to include information on drug‑eluting sinus implants, including the Propel™. Randomized trials and clinical practice guidelines relevant to adult sinusitis, postoperative care, and steroid‑eluting implants are referenced in the policy history as informing the medical necessity criteria and subsequent device‑specific guidance.
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