CurrentCapital BluecrossPolicy MP 1.152

Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Defines medical necessity, investigational use, and required diagnostic and treatment prerequisites for FESS in members with chronic rhinosinusitis; applicable to Capital Blue Cross products with benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyFunctional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Policy CodePolicy MP 1.152

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateFeb 18, 2025

Key ActionObtain preauthorization per the member's health benefit plan and document symptom duration, objective findings, and failed medical therapy prior to surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=12 weeksminimum symptom duration required for CRS diagnosis

>=2symptom count required

>=4 weeksminimum corticosteroid/irrigation duration

3%–7%CRS prevalence in adults

Varies

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Coverage Criteria for Functional Endoscopic Sinus Surgery (FESS)

Medical necessity criteria for FESS

Covered when ALL of the following are met

Overall coverage criteria: Member meets all listed diagnostic and treatment prerequisites

Symptom duration and composition: Symptoms present for at least 12 continuous weeks AND at least 2 of the following symptoms (at least 1 must be mucopurulent nasal drainage or nasal obstruction): mucopurulent nasal drainage (anterior or posterior), nasal obstruction (congestion), facial pain, facial pressure, anosmia or hyposmia, cough (pediatric)>= 12 weeks; >= 2 symptoms; at least 1 of (mucopurulent drainage or nasal obstruction)

Supported by chunk 1

Appropriate medical therapy attempted and failed, including: allergy evaluation/education and treatment when indicated; antibiotics when indicated; decongestants when indicated; topical and/or systemic corticosteroids for at least 4 weeks unless contraindicated; saline nasal irrigations for at least 4 consecutive weeks; treatment of rhinitis medicamentosa when present; and education on environmental irritants including tobacco smokesee text (≥4 weeks for corticosteroids and saline irrigations)

Supported by chunk 1

Objective diagnostic confirmation: Diagnosis supported by symptomatology AND one or more of: evidence of inflammation on nasal endoscopy or CT, or evidence of purulence from the paranasal sinuses or ostiomeatal complex; if CT was not obtained for diagnosis, a CT must be obtained prior to surgeryCT recommended when surgery is considered

Supported by chunks 1 and 2

Absence of urgent complications: No serious urgent complications (e.g., orbital cellulitis/abscess, intracranial extension, or other complication) that would require urgent or emergent surgery and preclude 4 weeks of medical therapy

Supported by chunk 2

The use of functional endoscopic sinus surgery (FESS) is considered investigational for the treatment of chronic rhinosinusitis when the medical necessity criteria listed in this policy are not met. In such cases there is insufficient evidence to support a general conclusion about health outcomes or benefit associated with the procedure, and the service may be denied.

The existence of this medical policy does not guarantee that FESS is a covered benefit under a member’s specific health benefit plan. Coverage and payment decisions must be based on the member’s applicable health benefit plan language; plans may exclude services, apply limits, or require preauthorization even when a service meets the policy’s medical necessity criteria. Members and providers should consult the member’s health benefit plan or contact Capital Blue Cross for benefit and preauthorization details.

Coding Information

Covered when medically necessary (procedure codes)CPTCovered

31237
31240
31253
31254
31255
31256
31257
31259
31267
31276

1–10 of 12

1/2

Associated diagnosis codes listedICD-10

J32.0	Chronic maxillary sinusitis.
J32.1	Chronic frontal sinusitis.
J32.2	Chronic ethmoidal sinusitis.
J32.3	Chronic sphenoidal sinusitis.
J32.4	Chronic pansinusitis.
J32.8	Other chronic sinusitis.
J32.9	Chronic sinusitis, unspecified

Actions Required by Providers

Prior Authorization

Prior Authorization and Benefit Determination

Preauthorization is required when specified by the member's health benefit plan. Providers must verify member coverage and any prior authorization requirements with Capital Blue Cross before scheduling surgery.

Confirm prior authorization requirements with the member's specific health benefit plan.
Services may be subject to benefit limits or exclusions per the member's plan.

Denial Risk

Denial Risk for Non‑covered or Investigational Services

Services may be denied if the procedure does not meet the criteria listed in this policy or if the service is not a covered benefit under the member's health benefit plan.

Procedures not meeting the medical necessity criteria in this policy are considered investigational and may be denied.

Background

Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder of the paranasal sinuses and nasal mucosa characterized by prolonged nasal and sinus symptoms lasting at least 12 weeks. Common presenting features include mucopurulent nasal drainage, nasal obstruction, facial pain or pressure, and anosmia or hyposmia; pediatric presentations may also include cough. CRS affects approximately 3%–7% of adults and is associated with substantial morbidity and reduced quality of life.

Functional endoscopic sinus surgery (FESS) is an endoscopic surgical approach intended to remove obstructing tissue and open sinus ostia to restore drainage and improve delivery of topical therapies. FESS is considered for patients with CRS who have persistent symptoms despite appropriate medical therapy and who meet the objective diagnostic and treatment prerequisites described in this policy.

Definitions

Chronic rhinosinusitis (CRS) definition and key diagnostic features

Minimum symptom durationSymptoms present for at least 12 continuous weeks

Required symptom count and compositionAt least 2 symptoms, with at least 1 being mucopurulent nasal drainage or nasal obstruction

Qualifying symptomsMucopurulent nasal drainage; nasal obstruction (congestion); facial pain; facial pressure; anosmia or hyposmia; cough (pediatric)

Objective diagnostic confirmationDiagnosis supported by symptomatology plus one or more: inflammation on nasal endoscopy or CT, or purulence from paranasal sinuses/ostiomeatal complex

Medical therapy prerequisiteAppropriate medical therapy attempted and failed (see medical therapy requirements) prior to considering surgery

Functional endoscopic sinus surgery (FESS) definition — procedural description