ModifiedColorado Rocky Mountain Health PlansPolicy CS138.S

Sinus Surgeries and Interventions

Clinical coverage criteria and coding guidance for balloon sinus ostial dilation and functional endoscopic sinus surgery (FESS) for members of Colorado Rocky Mountain Health Plans; defines medical necessity, limitations, and documentation expectations for sinus procedures.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySinus Surgeries and Interventions

Policy CodePolicy CS138.S

Change TypeClinical evidence and reference updatesstate-specific language edits

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain and document recent CT imaging and a trial of maximal medical therapy (e.g., intranasal corticosteroids ± oral steroids, saline irrigation, appropriate antibiotics) before requesting prior authorization for ESS or balloon ostial dilation.

SourceLink

POLICY UPDATE CHANGES

Removed content/language pertaining to the state of Louisiana.

Added language to indicate this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.

Updated Clinical Evidence and References sections to reflect the most current information.

12 weeksmin symptom duration (CRS)

>=4/yrRARS threshold

12 monthsrecent CT

97.5%technical success (pooled)

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Insufficientevidence: absorptive devices

Coverage and Medical Necessity Criteria

CRS — Medically Necessary Criteria

Covered when ALL of the following are met for Chronic Rhinosinusitis (CRS):

CRS duration and medical therapy: Symptoms lasting longer than 12 weeks AND persistence of symptoms despite recent medical management with full courses of intranasal corticosteroids (and/or oral corticosteroids when appropriate); antibiotic therapy if bacterial infection is suspected; and nasal lavage/irrigation when appropriate.12 weeks

from chunk 2

Imaging requirements: A recent CT scan (performed within 12 months) obtained after completion of medical management documenting which sinus has disease and extent of disease (percent opacification or Modified Lund-Mackay score).CT within 12 months

chunks 2,3,8

CT findings (one or more required): CT findings include one or more of: bony remodeling; bony thickening; opacified sinus; ostial obstruction (outflow tract obstruction) and mucosal thickening.

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Symptom concordance: Sinonasal symptoms (e.g., pain, pressure, or drainage) are present on the same side as CT scan findings.

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Procedure-specific limitation for BSD: For balloon sinus ostial dilation only, dilation is limited to the frontal, maxillary, or sphenoid sinuses.

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RARS — Medically Necessary Criteria

Covered when ALL of the following are met for Recurrent Acute Rhinosinusitis (RARS):

Episode frequency: Four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals between episodes.

chunks 3,9

Symptom concordance: Sinonasal symptoms (e.g., pain, pressure, or drainage) are present on the same side as CT findings.

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CT evidence for RARS: Recent CT scan demonstrating ostial obstruction (outflow tract obstruction) and mucosal thickening in the sinus to be treated (for BSD). For FESS: for maxillary, frontal, or sphenoid sinuses both ostial obstruction and mucosal thickening must be present; for ethmoid sinus, mucosal thickening must be present.

chunk 3

FESS — Additional Indications

FESS is also medically necessary when any one of the following CT-confirmed conditions is present:

Complications and other indications: Complications of sinusitis such as abscess; symptomatic concha bullosa; symptomatic mucocele; polyposis with obstructive symptoms (see CRS criteria for polyposis); or sinonasal tumor.

chunk 4

Indications for balloon sinus ostial dilation

Covered when ALL of the following are met

Primary coverage criteria: 1) Patient has symptoms consistent with CRS or RARS; 2) Appropriate medical therapy failed (e.g., saline irrigation, topical intranasal corticosteroids, antibiotics as indicated); 3) Objective confirmation of sinonasal disease by nasal endoscopy or CT showing mucosal thickening/opacification; 4) Procedure is performed to dilate an obstructed sinus ostium (frontal, maxillary, or sphenoid) or as an adjunct to other sinus surgery; 5) Final decision on technique is by the attending surgeon.

Based on AAO-HNS and ARS consensus statements

Indications for sinus surgery or ostial dilation

Covered when ALL of the following are met

All criteria: 1) Clinical diagnosis of CRS or RARS documented; 2) Objective confirmation of sinonasal inflammation by nasal endoscopy or CT; 3) Failure of appropriate/optimal medical therapy (e.g., saline irrigation, topical intranasal corticosteroids, and other selected adjunctive treatments); 4) Procedure selection (e.g., balloon ostial dilation or FESS) is consistent with surgeon judgment and the extent of disease.

Derived from AAO-HNS, ARS and allergy society guidance

Coverage for ESS and balloon dilation when medically necessary

Covered when ALL of the following are met:

Clinical duration: Presence of symptoms consistent with CRS or RARS for the recommended duration (e.g., >=12 weeks for CRS per ICAR-RS) or a recurrent pattern consistent with RARS.>=12 weeks for CRS where applicable

ICAR-RS specifies 12-week symptom duration as a criterion

Failed maximal medical therapy: Documented trial of maximal medical therapy (MMT) appropriate to the condition, including topical intranasal corticosteroids and saline irrigation; antibiotics or other adjuncts as indicated.Minimum trial periods per guideline (e.g., >=8 weeks in some EUFOREA scenarios)

EUFOREA and ICAR-RS require MMT prior to surgery in most cases

Objective evidence of disease on sinonasal CT and/or endoscopy (inflammation or purulence) and, when cited, preoperative symptom score (e.g., SNOT-22 >=20 or Lund–Mackay CT score >=1 in some recommendations).

Endoscopic resection for low-stage sinonasal malignancy

Covered when ALL of the following are met:

Tumor stage: Low-stage sinonasal malignancy (for example T1-2 or Kadish A-B) where endoscopic approach is clinically appropriate.Low-stage only per evidence

Systematic review showed comparable outcomes for endoscopic versus open approaches in low-stage disease (chunk 54)

Surgical intent: Surgeon documents that endoscopic resection can achieve oncologic goals equivalent to an open approach for the tumor in question.Documentation of appropriateness

Evidence is limited for high-stage malignancies; endoscopic approach reasonable for low-stage

Self-expanding absorptive sinus ostial dilation devices

Coverage stance:

Evidence requirement: Self-expanding absorptive sinus ostial dilation devices are not supported for coverage due to insufficient evidence; existing studies are small and lack comparison groups.N/A

chunk 64

Balloon sinus ostial dilation is considered unproven and not medically necessary for treatment of sinonasal polyps or tumors. The policy states that BSD lacks sufficient evidence of efficacy for these indications and therefore should not be used to manage polyps or neoplastic disease.

Balloon dilation is not appropriate for patients who do not have sinonasal symptoms and who lack positive CT findings. The AAO-HNS consensus specifically indicates BSD is inappropriate when both symptoms and CT evidence of disease are absent, and the policy excludes BSD for CRS or RARS cases that do not meet the stated clinical and imaging criteria.

Per published guidance, patients with severe nasal polyposis are not considered suitable candidates for the XprESS multi‑sinus dilation system; NICE recommends XprESS for uncomplicated CRS without severe polyposis and EUFOREA supports a role for balloon techniques in milder cases of CRS. When severe polyposis is present, alternative approaches such as standard FESS may be more appropriate.

Self‑expanding absorptive sinus ostial dilation devices are not supported for coverage because the current evidence is insufficient. Existing studies are small, lack comparison groups, and do not provide adequate data to establish effectiveness or long‑term benefit.

This Medical Policy does not apply to the state of Nebraska. Providers and reviewers should refer to the Nebraska‑specific version of the policy for state‑governed coverage rules and any differing requirements.

Functional Endoscopic Sinus Surgery (FESS) is considered unproven and not medically necessary when the clinical criteria for CRS or RARS are not met. The policy specifies that FESS lacks sufficient evidence of efficacy for cases that do not satisfy the documented symptom duration, failed medical therapy, and objective imaging/endoscopic confirmation requirements.

Balloon sinus ostial dilation has been shown to provide no benefit over placebo for barometric pressure‑related 'sinus' headache in patients without CT evidence of mucosal disease; randomized and comparative studies found no significant difference between active BSD and sham procedures in this population. Consequently, BSD is considered ineffective for isolated barometric pressure‑related headache when CT does not document mucosal disease.

Balloon dilation should not be used as a substitute for more extensive FESS in patients with advanced or extensive disease. Specialty society guidance and practice parameters note that balloon techniques are appropriate for limited or localized disease and that the standard FESS approach—removal of inflamed bony partitions and more extensive surgical opening—may be required for patients with more than minor disease or when long‑term resolution is the goal.

Use of self‑expanding absorptive sinus ostial dilation devices is not recommended as a routine alternative to standard surgical techniques. Given the small, uncontrolled pilot studies and lack of comparative data, these devices remain investigational and are not supported for routine clinical use.

Procedure and Device Codes

Applicable CPT CodesCPT

31240	Nasal/sinus endoscopy, surgical; with concha bullosa resection.
31253	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed.
31254	Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior).
31255	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior).
31256	Nasal/sinus endoscopy, surgical, with maxillary antrostomy.
31257	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy.
31259	Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus.
31267	Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus.
31276	Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed.
31287	Nasal/sinus endoscopy, surgical, with sphenoidotomy;.

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Procedures discussed (no codes in excerpt)mixed

No codes listed

Device product code (FDA)mixed

LRC	FDA product code for ENT manual surgical instruments including balloon dilation devices

inv-21: Recent CT — performed within 12 months of planned procedure.

Recent CT timingCT scan performed within 12 months of the planned procedure

PurposeObtain after completion of medical management to document which sinuses are diseased and extent of disease

Imaging typeNon-contrast sinus CT preferred for preoperative anatomic definition

inv-22: CT Lund-Mackay score threshold (EUFOREA) — >= 1 (for offering ESS in uncomplicated CRSsNP).

Lund-Mackay threshold>= 1 CT Lund-Mackay score (EUFOREA) for offering ESS in uncomplicated CRSsNP

Context

Prior Authorization, Documentation, and Pre-Procedure Expectations

Prior Authorization

Prior Authorization: medical therapy failure + objective confirmation

Prior authorization is required and will be assessed for objective confirmation of disease and documentation of failed appropriate medical therapy prior to approval for sinus procedures.

Prior authorization must document failure of appropriate medical therapy and objective findings (nasal endoscopy or non-contrast CT) for the sinus(s) planned for treatment.
Coverage decisions reference federal, state, and contractual benefit terms which may supersede policy guidance.

Prior Authorization

Prior Authorization: failed medical therapy + objective confirmation

Members should have attempted and failed stepwise medical management before surgical authorization is considered. Lack of documentation of these steps may lead to denial.

Required trial of medical therapy typically includes: saline nasal irrigation, topical intranasal corticosteroids (minimum trial periods per guideline; e.g., >= 8 weeks when applicable), and adjuncts such as oral corticosteroids when appropriate and antibiotics if bacterial infection is suspected.

Definitions and Key Concepts

inv-45: Acute Rhinosinusitis (ARS) definition.

DefinitionAcute Rhinosinusitis (ARS): inflammation with purulent nasal drainage plus nasal obstruction and/or facial pain/pressure/fullness for up to 4 weeks

Etiology noteTypically a clinical condition of the nasal and paranasal mucosa; bacterial infection suspected when symptoms fail to improve or worsen after 10 days

Diagnostic emphasisMost uncomplicated acute/subacute cases are diagnosed clinically and usually do not require imaging

inv-46: Chronic Rhinosinusitis (CRS) definition.

DefinitionChronic Rhinosinusitis (CRS): inflammation of the paranasal sinuses persisting >12 weeks with >=2 symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure, or decreased smell) and objective evidence of inflammation

Objective documentation required

Clinical Background

Chronic rhinosinusitis (CRS) is inflammation of the paranasal sinuses lasting longer than 12 weeks. CRS typically presents with at least two symptoms such as mucopurulent nasal drainage, nasal obstruction, facial pain/pressure/fullness, or decreased smell, and requires objective evidence of sinonasal inflammation (endoscopic findings or CT mucosal disease) to guide decisions about interventions including FESS or balloon ostial dilation.

Policy Revision History and Recent Changes

The policy references contemporary systematic reviews, clinical practice guidelines, and outcome studies supporting its recommendations. Key sources include AAO‑HNS guidelines and expert statements, EUFOREA and ICAR‑RS consensus documents, randomized trials and comparative studies of balloon dilation versus medical therapy or FESS, and a range of systematic reviews and long‑term outcome analyses updating the clinical evidence base.

The most recent policy revision history lists template updates and jurisdictional clarifications. The Summary of Changes entries include a template update, removal of language pertaining to Louisiana, addition of the statement that the policy does not apply to Nebraska, and updating clinical evidence and references; the policy identifier referenced is CS138.S.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySinus Surgeries and Interventions

Policy CodePolicy CS138.S

Change TypeClinical evidence and reference updatesstate-specific language edits

Effective DateAug 1, 2025

Next Review DateN/A

SourceLink

On This Page

CT evidence (Lund-Mackay >=1 in some recommendations); SNOT-22 >=20

AAO-HNS, ICAR-RS and EUFOREA emphasize CT, endoscopy, and symptom scores prior to ESS

EUFOREA recommends CT evidence of disease is mandatory and Lund-Mackay >=1 supports offering ESS in uncomplicated CRSsNP

UseServes as one objective imaging threshold when considering ESS per EUFOREA guidance

inv-23: SNOT-22 preoperative score — >= 20 (ICAR-RS and EUFOREA supporting eligibility).

Preoperative SNOT-22SNOT-22 score >= 20 as a criterion supporting eligibility for ESS

Guideline sourceIncluded in ICAR-RS and cited by EUFOREA as part of preoperative assessment for surgery

RoleUsed with objective endoscopy/CT findings to confirm symptom burden prior to ESS

Documented failure of medical therapy must be recent and specific to the sinus disease being treated.

Documentation Required

Imaging and conservative therapy prior to authorization

Obtain non-contrast CT sinus imaging and document conservative therapy prior to authorization for surgical procedures; CT should be recent (within 12 months) and performed after medical management when feasible.

Non-contrast CT of the sinuses is the imaging method of choice to confirm sinus inflammation and to define anatomy prior to surgery.
CT imaging should document which sinus has disease and extent (percent opacification or Lund-Mackay/Modified Lund-Mackay score).

Denial Risk

Imaging and prior therapy expectations

Absence of CT imaging or failure to attempt/record prior medical therapy may result in denial of authorization for ESS or dilation procedures.

For RARS or CRS, CT without contrast performed within 12 months is expected for preoperative planning and objective confirmation.
Medical therapy and imaging should be documented in the medical record submitted with the authorization request.

Documentation Required

Required clinical documentation

Submit complete clinical documentation with prior authorization requests to demonstrate that coverage criteria are met.

Clinical history with symptom duration (>12 weeks for CRS) and description of cardinal symptoms.
Details of prior medical management including duration, doses, and response (e.g., topical intranasal corticosteroids, saline irrigation, antibiotics, oral steroids when appropriate).
Operative history if prior sinus surgery has been performed.

Documentation Required

Required objective findings and imaging

Objective evidence must include endoscopic findings and/or CT imaging demonstrating sinonasal inflammation or obstruction corresponding to symptoms and to the sinus(s) proposed for treatment.

Preferred documentation: nasal endoscopy demonstrating mucosal inflammation, purulence, polyps, or other abnormality; OR non-contrast CT showing mucosal thickening, opacification, ostial obstruction, or bony remodeling.
Record CT-based scoring (Modified Lund-Mackay or percent opacification) and clearly map imaging findings to the planned procedure.

Note

Check plan-specific requirements

Check plan-specific requirements and applicable federal/state/contractual benefit terms prior to requesting authorization; these govern coverage when conflicts exist.

If federal, state, or contractual terms differ from this policy, the governing terms control.
Some plans may use third-party tools (e.g., InterQual) to inform authorization decisions; follow the plan's submission process.

Step Therapy

Medical therapy first

Medical management should be the first line of treatment; surgical intervention is considered when appropriate medical therapy has failed.

Recommend initial therapies such as saline irrigation and topical intranasal corticosteroids before considering surgery.
Document rationale for escalation to surgery when medical therapy is inadequate or not tolerated.

Step Therapy

Stepwise medical therapy before surgery

Follow a stepwise approach to medical therapy before surgery; document each step and its outcome in the medical record submitted for authorization.

Step 1: Saline nasal irrigation and topical intranasal corticosteroid (minimum trial as indicated; e.g., >= 8 weeks when applicable).
Step 2: Add adjunct therapies as indicated (short course oral corticosteroids for severe inflammation, antibiotics when bacterial infection suspected, intranasal antihistamines if allergic component).
Step 3: Consider referral for endoscopy and obtain CT imaging after medical optimization if symptoms persist.

Inflammation documented by polyps, edema, purulent mucus, nasal endoscopy, or radiographic imaging

Minimum symptom durationSymptoms lasting longer than 12 weeks is required per guidelines

inv-47: Recent Computed Tomography (CT) Scan — within 12 months.

Recency thresholdCT considered recent if performed within 12 months of the planned procedure

Timing guidanceImaging studies should generally be obtained after completion of optimal medical therapy when surgery is being considered

PurposeCT provides anatomic detail to guide surgery and documents extent and location of disease

inv-48: Modified Lund-Mackay Scoring System — scoring description.

Scoring range per sinusEach sinus scored 0–5 based on percent opacification: 0=0%, 1=1–25%, 2=26–50%, 3=51–75%, 4=76–99%, 5=100%

Ostiomeatal complexOMC scored 0–2 for patency: patent, partially obstructed, or completely obstructed

Total scoreEach side graded and summed; maximum total score is 54

inv-49: Recurrent Acute Rhinosinusitis (RARS) — >=4 episodes/year definition.

Frequency thresholdRecurrent Acute Rhinosinusitis (RARS): defined as >= 4 episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals

Episode criteriaEach episode should meet ABRS diagnostic criteria (e.g., failure to improve within 10 days or double worsening) or be confirmed bacterially when possible

DocumentationExamination during an ABRS episode among the four per year is preferred to substantiate diagnosis if laboratory confirmation is unavailable

inv-50: RARS — clinical definition and note.

Clinical definitionRARS: multiple episodes of acute bacterial rhinosinusitis over 12 months; considered a potential indication for sinus ostial dilation when supported by symptoms and CT/endoscopic evidence

Therapeutic optionAAO-HNS and ARS identify BSD/SOD as a therapeutic option for selected patients with RARS who have failed appropriate medical therapy

Objective supportCT evidence of ostial occlusion and mucosal thickening supports consideration of SOD for RARS

inv-51: Objective confirmation — evidence via endoscopy or CT.

Acceptable objective methodsObjective confirmation of sinonasal inflammation can be provided by nasal endoscopy or CT showing mucosal thickening or opacification

Endoscopy findingsNasal endoscopy documenting sinonasal abnormality, purulence, polyps, or edema supports diagnosis

Imaging roleCT demonstrates abnormal mucosa, opacified sinuses, and anatomy for surgical planning

inv-52: Objective documentation of sinonasal inflammation — visualization or CT findings.

Direct visualizationObjective documentation may be established by anterior rhinoscopy or nasal endoscopy showing mucosal inflammation, purulence, or polyps

CT findingsCT demonstrating mucosal thickening, opacified sinuses, ostial obstruction, or bony changes documents inflammation radiographically

Requirement for proceduresClinical diagnosis should be supported by endoscopy or CT prior to balloon dilation or ESS per AAO-HNS/ARS guidance

inv-53: Balloon sinus ostial dilation (BSD/Balloon dilation/XprESS) — definition of technique.

DefinitionBalloon sinus ostial dilation (BSD): technique to dilate obstructed frontal, maxillary, or sphenoid sinus ostia using balloon catheters, performed standalone or with other instruments

IndicationsUsed to dilate ostia (frontal, maxillary, sphenoid) alone or adjunctively during sinus surgery; final technique choice by surgeon

LimitationsNot appropriate for patients without sinonasal symptoms or without CT evidence of disease; not suitable for severe polyposis per guidance

inv-54: Maximal medical therapy (MMT) — definition and typical components.

Core componentsMaximal medical therapy (MMT) typically includes topical intranasal corticosteroids and saline irrigation; antibiotics and oral corticosteroids when indicated

Expected trial durationPolicy and guidelines expect a documented trial of MMT (e.g., minimum ~8 weeks in some EUFOREA/ICAR-RS scenarios) prior to surgery

DocumentationRecords should show prior conservative therapy and failure before authorizing ESS or BSD

inv-55: Lund-Mackay CT score — CT scoring system used to quantify disease severity.

PurposeLund-Mackay CT score quantifies sinus opacification to assess disease severity on CT

Modified versionZinreich modified Lund-Mackay by increasing per-sinus scale to 0–5 (Modified Lund-Mackay) for percent opacification assessment

Use in guidanceEUFOREA and other groups reference Lund-Mackay thresholds (e.g., >=1) when recommending ESS in select patients

inv-56: Supporting evidence — references to systematic reviews, guidelines, and outcome studies.

Guidelines and reviewsPolicy cites systematic reviews, clinical practice guidelines (AAO-HNS, ICAR-RS, EUFOREA), and outcome studies informing indications and evidence for BSD and ESS

Key guideline roleAAO-HNS, ARS, ACR, EUFOREA and ICAR-RS provide consensus and evidence-based recommendations referenced in the policy

Evidence limitationsSeveral reviews note limited RCT evidence comparing BSD vs ESS and call for standardized outcome measures and longer-term data