ModifiedColorado Rocky Mountain Health PlansPolicy 2026T0571T

Sinus Surgeries and Interventions (Balloon sinus ostial dilation and Functional Endoscopic Sinus Surgery)

Medical policy governing coverage criteria for balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and related sinus interventions for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySinus Surgeries and Interventions

Policy CodePolicy 2026T0571T

Change TypeAdministrative consolidation — shared policy created for Oxford plan application

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document recent CT imaging (within 12 months) plus objective findings and failure of appropriate medical therapy when requesting prior authorization for sinus surgery or balloon dilation.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and archived previous policy versions.

12 monthsCT recency

4/yrRARS threshold

12 weeksCRS duration

1.4 daysMean recovery

97.5%

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

BSD technical success

Coverage Criteria for Sinus Procedures

CRS — Balloon dilation or FESS

Covered when ALL of the following are met

Duration: Symptoms have lasted longer than 12 weeks>12 weeks

Prior medical management: 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

Recent CT confirmation: Recent CT scan for each sinus to be treated obtained after completion of medical management with documentation of which sinus has disease and extent of disease (percent opacification or Modified Lund-Mackay score)CT within 12 months

CT findings must include one or more: bony remodeling, bony thickening, opacified sinus, or ostial obstruction and mucosal thickening

Symptom-imaging concordance: Sinonasal symptoms such as pain, pressure, or drainage are present on the same side as CT findings

Anatomic limits for balloon dilation: For balloon sinus ostial dilation only, dilation is limited to the frontal, maxillary, or sphenoid sinuses

RARS — Balloon dilation or FESS

Covered when ALL of the following are met

Episode frequency: Four or more episodes per year with distinct symptom-free intervals>=4/year

Symptom-imaging concordance: Sinonasal symptoms (pain, pressure, drainage) present on the same side as CT findings

CT evidence specific to procedure: For balloon dilation: ostial obstruction and mucosal thickening in the sinus to be dilated; For FESS: for maxillary, frontal, or sphenoid sinuses both ostial obstruction and mucosal thickening are required; for ethmoid sinus, mucosal thickening is sufficient.

FESS — Other indications

FESS is also covered when any of the following CT-confirmed conditions are present

Complications of sinusitis such as abscess

Anatomic pathology: Symptomatic concha bullosa or symptomatic mucocele

Polyposis with obstructive symptoms (see CRS with polyps criteria)

Tumor: Sinonasal tumor

Appropriate use (general)

Covered when ALL of the following are met

Clinical diagnosis of CRS or RARS based on symptoms of sinusitis

Symptom-based diagnosis required

Objective confirmation: Objective documentation of sinonasal inflammation by nasal endoscopy showing sinonasal abnormality OR CT demonstrating mucosal thickening/opacification

CT recommended prior to BSD; CT may be used to exclude aggressive infection or neoplasm

Failure of medical therapy: Failure of appropriate medical therapy (e.g., topical intranasal corticosteroids, saline irrigation, or other medical management) prior to consideration of BSD

Medical therapy recommended by AAO-HNS guidelines before surgical management

Setting and adjunct: BSD may be used as standalone procedure or adjunct to FESS; may be performed in-office or operating room depending on case complexity

RARS specific

Covered when ALL of the following are met

RARS diagnostic criteria: Patients meet RARS diagnostic criteria (e.g., ≥4 episodes of acute bacterial rhinosinusitis in prior 12 months) and have CT or endoscopic evidence of ostial disease

Evidence from RCT and prospective studies supports BSD+medical management in selected RARS patients

Pediatric CRS

Covered when ALL of the following are met

Age/indication: Children aged ≥2 years with CRS refractory to appropriate prolonged medical management

Pediatric studies show symptom and QOL improvement after BSD but evidence base is limited

Consider adenoidectomy first: Adenoidectomy should be considered prior to sinus surgery (including BSD) where indicated, typically after at least 3 months of failed medical management

AAO-HNS pediatric indicators recommend adenoidectomy as first-line surgical option when indicated

Covered surgical options

Policy-aligned coverage stance summarized from guideline and evidence statements

Balloon ostial dilation (BSD/XprESS): Covered for selected patients with CRS or RARS who have failed appropriate medical therapy and have objective confirmation of sinonasal disease (nasal endoscopy or CT); may be used alone to dilate frontal, maxillary, or sphenoid ostia or in conjunction with other instruments; recommended consideration for uncomplicated CRS without severe nasal polyposis and for milder/early diseaseN/A

Supported by ARS, AAO-HNS, and NICE positions; long-term advantage versus FESS not conclusively established

Functional Endoscopic Sinus Surgery (FESS): Covered as an established surgical option for CRS refractory to appropriate medical therapy; extent of surgery (limited, full-house, extended, radical) chosen based on disease severity and surgeon judgment; greater extent may yield greater symptom improvement and lower revision rates in some contextsN/A

Systematic reviews and RCT data support efficacy for improving QOL (SNOT-22) and objective outcomes; used for a wide spectrum of sinonasal disease

Indications for endoscopic sinus surgery (ESS/FESS)

Covered when ALL of the following are met:

ESS Indication: Patient has CRS (with or without nasal polyps), allergic fungal rhinosinusitis, RARS, mucocele, sinonasal polyposis with airway obstruction or suboptimal asthma control, unilateral sinus opacification consistent with CRS, or complications of sinusitis

Based on AAO-HNS clinical indicators

Objective evidence of disease by nasal endoscopy and/or CT imaging demonstrating sinus inflammation or opacification

AAO-HNS and ACR recommend CT when ESS is considered and after medical therapy

Failed medical therapy: Failure of appropriate medical therapy or maximal medical therapy documented prior to surgery

ICAR-RS and guideline sources define failure of MMT as prerequisite for ESS

Symptom burden: Relevant symptom measures such as SNOT-22 documented; ICAR-RS and EUFOREA reference SNOT-22 >=20 as supportive of surgical consideration

Balloon sinuplasty and ostial dilation

Covered with criteria and limited by evidence strength:

Balloon/Balloon-based ostial dilation: Balloon sinuplasty may be considered for selected patients with CRS or RARS when criteria for surgical intervention are met and anatomy is suitable; randomized trials and prospective studies report improved QOL but evidence is mixed

Guidance varies across societies; AAO-HNS expert consensus and multiple trials cited

Self-expanding absorptive devices: Use of self-expanding absorptive sinus ostial dilation devices is considered investigational/insufficient due to limited studies lacking comparison groups and small sample sizes

Pilot studies exist but evidence insufficient

Balloon sinus ostial dilation (BSD) and self-expanding absorptive sinus ostial dilation devices have limited and specific roles. The policy states that BSD is unproven and not medically necessary for treatment of sinonasal polyps or tumors, and that self-expanding absorptive sinus ostial dilation is unproven and not medically necessary for evaluation or treatment of sinusitis and other conditions because available studies are small or lack appropriate comparison groups.

Balloon dilation should only be performed when there is concordant clinical and imaging evidence of sinonasal disease. Per AAO-HNS consensus and the coverage criteria, balloon dilation is not appropriate for patients who do not have both sinonasal symptoms (e.g., pain, pressure, drainage) and positive CT findings; CT scanning is required prior to BSD and a CT that does not show disease contraindicates the procedure.

Use of balloon dilation for isolated headache or sleep apnea is not supported unless the patient otherwise meets criteria for CRS or RARS with objective disease. AAO-HNS consensus specifically notes balloon dilation is not appropriate for management of headache or sleep apnea in patients who do not otherwise meet diagnostic criteria, and randomized and comparative studies of BSD in headache without CT evidence of mucosal disease have not shown superiority over placebo or medical therapy.

Balloon dilation is not endorsed as a universal substitute for Functional Endoscopic Sinus Surgery (FESS). Society guidance and evidence summaries conclude that while BSD can improve short-term outcomes for selected patients with limited disease, current evidence does not demonstrate a clear long-term advantage over FESS, and it remains debatable whether BSD is an adequate alternative to traditional FESS for broader disease presentations.

Self-expanding absorptive sinus ostial dilation devices are considered investigational due to insufficient evidence. Pilot studies are small and lack comparison groups; therefore these devices are not supported for routine use. By contrast, FESS remains an established surgical procedure for appropriately selected indications, and devices used in FESS may be subject to FDA regulation while the procedure itself is not.

This policy provides guidance for UnitedHealthcare standard benefit plans but does not replace the member specific benefit plan document. Where the policy conflicts with a member's specific plan terms, the member specific benefit plan governs and must be followed when making coverage determinations.

FESS and BSD are considered not medically necessary when criteria in this policy are not met. Procedures for CRS or RARS that lack the required duration, failure of medical therapy, objective confirmation (endoscopy or CT), or symptom–imaging concordance may be denied. Additionally, self-expanding absorptive dilation is categorized as unproven and not medically necessary for routine use given current evidence limitations.

Randomized and controlled studies examining BSD for barometric pressure–related sinus headache or for rhinogenic headache without CT evidence of mucosal disease have not demonstrated superiority of BSD over placebo or medical therapy. These findings support the policy position that BSD for such indications lacks convincing benefit and is not routinely supported.

Balloon dilation should not be used as first-line therapy in patients with only minor disease that may respond to medical management. Guidance notes many patients selected for BSD have limited disease that might be amenable to continued medical therapy; BSD without documentation of prior appropriate medical management and objective disease may be considered not medically necessary.

Placement of self-expanding absorptive ostial dilation devices as a standalone therapy is unsupported by sufficient evidence. Available pilot studies are limited by small sample sizes, lack of controls, and short follow-up, and therefore use of these devices remains investigational and may be considered not medically necessary or unproven.

Procedure and Product Coding

Applicable Procedure 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;

1–10 of 16

1/2

FDA device/product codes referencedmixed

LRC	FDA product code category: instrument, ENT, manual surgical (includes dilation devices)

inv-22: RARS episode count

RARS episode count>= 4 episodes per year

DocumentationAt least one episode preferably confirmed by CT or endoscopy

Timing windowEpisodes counted within prior 12 months

inv-23: Recent CT timeframe

Recent CT timeframeCT performed within 12 months of planned procedure

PurposeCT recommended after completion of medical management to document diseased sinuses and extent

Modality

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Verify prior authorization with member plan

Prior authorization is required for listed procedures and must be verified with the member-specific benefit plan prior to scheduling. Coverage is determined by the member’s benefit plan and applicable federal/state mandates; in the event of conflict the member-specific plan governs.

Prior authorization required per payer medical policy and may vary by member plan.
Verify eligibility and prior authorization requirements with the member’s benefit plan before performing services.

Prior Authorization

Prior authorization requires objective disease and failed medical therapy

Prior authorization requires documentation of objective disease and failure of appropriate medical therapy before surgical intervention is authorized.

Confirm failure of appropriate medical therapy (see medical management below) and include objective evidence of disease.
Objective evidence may include nasal endoscopy findings and/or CT imaging (performed within 12 months of planned procedure).

Definitions, Background, and Context

Chronic rhinosinusitis (CRS) is defined as inflammation of the paranasal sinuses persisting for more than 12 weeks with at least two core symptoms (for example, mucopurulent drainage, nasal obstruction, facial pressure/pain, or decreased smell) and objective evidence of inflammation such as polyps, edema, purulent mucus, or radiographic findings. FESS is an established surgical option for medically refractory CRS; balloon sinus ostial dilation is a minimally invasive alternative for selected patients with appropriate anatomy and objective disease who have failed medical therapy.

inv-47: Chronic Rhinosinusitis (CRS)

Core definitionChronic rhinosinusitis (CRS) is inflammation of the paranasal sinuses persisting >12 weeks with ≥2 symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell) and requires documented inflammation by polyps, edema, purulent mucus, or CT findings.

Objective confirmationInflammation documented by purulent mucus or edema in middle meatus/anterior ethmoid, polyps, or radiographic imaging showing sinus inflammation.

Duration thresholdMinimum symptom duration: >12 weeks

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySinus Surgeries and Interventions

Policy CodePolicy 2026T0571T

Change TypeAdministrative consolidation — shared policy created for Oxford plan application

Effective DateJan 1, 2026

Next Review DateN/A

SourceLink

On This Page

Evidence shows similar efficacy to FESS in selected patients; patient selection important

EUFOREA and ICAR-RS criteria

Non-contrast sinus CT preferred for preoperative evaluation

inv-24: SNOT-22 threshold

SNOT-22 threshold>= 20

ContextReferenced by ICAR-RS and EUFOREA as supportive of surgical consideration when documented preoperatively

UseSupports symptom burden concordant with objective findings for ESS consideration

inv-25: Lund-Mackay CT score (EUFOREA)

Lund-Mackay CT score (EUFOREA)>= 1

ContextEUFOREA recommends Lund-Mackay >=1 as part of criteria for offering ESS in uncomplicated CRSsNP

UseCT score used to document presence of disease and guide surgical decision-making

For balloon sinus ostial dilation (BSD), ensure CT and symptom concordance and that dilation is limited to frontal, maxillary, or sphenoid sinuses per policy.

Document whether BSD is being used alone or adjunctive to FESS.

Documentation Required

Objective evidence required for ESS

Functional endoscopic sinus surgery (ESS/FESS) requires objective confirmation of disease and documented failure of maximal medical therapy to meet authorization criteria.

Include objective findings of sinonasal inflammation on nasal endoscopy and/or CT imaging (use Lund–Mackay or other validated scoring where applicable).
Imaging should generally be obtained after optimal medical therapy.
Document presence of cardinal symptoms for ≥12 weeks when applicable and any validated symptom scores (e.g., SNOT-22).

Documentation Required

Required documentation for medical necessity review

Medical necessity review requires complete medical records demonstrating prior medical therapy, objective diagnostic testing, and symptom documentation.

Recent CT imaging of the paranasal sinuses (performed within 12 months) with documentation of which sinuses are affected and extent of disease (percent opacification or Modified Lund–Mackay score).
Documentation of prior medical management: intranasal corticosteroids (and oral corticosteroids when appropriate), saline irrigation, antibiotics when bacterial infection suspected, and duration/response.
Office records showing preoperative symptoms, nasal endoscopy findings, and any prior sinus surgeries or interventions.
Procedure notes indicating the specific sinus(s) to be treated and rationale linking symptoms to imaging/endoscopy findings.

Documentation Required

Conservative therapy before surgery

Conservative medical therapy is required and must be documented as failed prior to surgical management for most CRS and RARS indications.

Trials should include topical intranasal corticosteroids and saline irrigation as foundational therapy.
Consider adjunctive therapies when appropriate (oral corticosteroids, antibiotics for suspected bacterial infection, intranasal antihistamines, decongestants).
Document duration and adherence to therapies and the clinical response (or lack thereof).

Documentation Required

Documented trial of medical therapy

Document a trial of medical therapy with specifics on agents, duration, and response to support that medical management has been attempted and failed.

Record dates and doses of intranasal corticosteroids and any systemic corticosteroid courses.
Record use and duration of saline irrigations and any antibiotic therapy (including rationale if prolonged or culture-directed therapy used).
If relevant, include SNOT-22 scores or other validated symptom measures pre- and post-treatment to demonstrate persistence of symptomatic disease.

inv-48: Modified Lund-Mackay Score

DefinitionModified Lund-Mackay scoring: CT-based per-sinus opacification scale (0 = 0% to 5 = 100%); ostiomeatal complex scored 0–2; total score per side summed to maximum 54 (Zinreich modification).

PurposeQuantifies extent of sinus opacification to document disease severity and track change after treatment

Alternative/validationComputerized 3D and 2D OMC methods show strong correlation; Lund-Mackay less sensitive to change than volumetric methods.

inv-49: Recent CT Scan

Recent CT ScanCT is considered recent when performed within 12 months of the planned procedure

RoleCT recommended after medical management to document which sinuses are diseased and extent of disease

TypeNon-contrast sinus CT provides preoperative anatomic detail

inv-50: Recurrent Acute Rhinosinusitis (RARS)

RARS definitionRecurrent acute rhinosinusitis (RARS) is defined as ≥4 episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals between episodes.

Episode confirmationConfirming at least one bacterial episode by CT or endoscopy is preferred when ABRS is not laboratory-confirmed.

Clinical relevanceRARS may be considered for BSD when CT or endoscopy demonstrates ostial disease; trials show BSD plus medical management improved QOL vs medical management alone in RARS patients.

inv-51: RARS — supplemental definition/context

Supplemental contextAAO-HNS and HTA evidence support a role for BSD in RARS when diagnostic criteria are met and CT demonstrates ostial occlusion and mucosal thickening.

Evidence noteRandomized trial (Sikand et al.) demonstrated improved QOL with BSD+medical management in properly diagnosed RARS patients followed to 48 weeks.

Clinical requirementSelect patients should have failed appropriate medical therapy and have objective confirmation of disease before BSD is considered.

inv-52: CRS — supplemental definition/context

Supplemental CRS contextCRS management requires both symptom criteria (>12 weeks, ≥2 symptoms) and objective confirmation (endoscopy or CT); BSD or FESS considered when medical therapy fails.

Objective testsNasal endoscopy demonstrating sinonasal abnormality or CT demonstrating mucosal thickening/opacification required for intervention consideration.

Treatment pathwayMaximal medical therapy (topical intranasal corticosteroids, saline irrigation, antibiotics when indicated) should be attempted before surgical options.

inv-53: Balloon sinus ostial dilation (BSD / balloon sinuplasty / XprESS)

DefinitionBalloon sinus ostial dilation (BSD/balloon sinuplasty/XprESS) is a minimally invasive technique using balloon catheters to dilate obstructed frontal, maxillary, or sphenoid sinus ostia; can be performed standalone or adjunctively with other instruments.

IndicationsTherapeutic option for selected patients with CRS or RARS who have failed appropriate medical therapy and have objective confirmation of disease.

LimitsDilation is limited to frontal, maxillary, or sphenoid ostia; selection dependent on anatomy and disease extent.

inv-54: Functional Endoscopic Sinus Surgery (FESS)

DefinitionFunctional Endoscopic Sinus Surgery (FESS) is a minimally invasive, mucosal-sparing endoscopic surgical approach to open and ventilate the paranasal sinuses; extent ranges from limited to full-house, extended, or radical procedures based on disease severity.

UseIndicated for CRS refractory to medical therapy and for conditions such as allergic fungal rhinosinusitis, mucocele, sinonasal polyposis with obstruction, RARS, and complications of sinusitis.

EvidenceSystematic reviews/meta-analyses support improved QOL (SNOT-22) and objective outcomes with greater extent of ESS often yielding larger symptom improvement and lower revision rates.

inv-55: Maximal medical therapy (MMT)

DefinitionMaximal medical therapy (MMT) is a documented course of appropriate medical treatments such as topical intranasal corticosteroids and saline irrigation, with antibiotics or systemic anti-inflammatory antibiotics when indicated, that has failed to relieve CRS symptoms prior to considering surgery.

ComponentsIncludes saline nasal irrigation and topical intranasal corticosteroids as recommended by AAO-HNS; systemic antibiotics when bacterial infection suspected.

DocumentationMedical records should document trials of these therapies before authorization for BSD or ESS is considered.

inv-56: Lund-Mackay score

DefinitionLund-Mackay score is a CT-based scoring system used to quantify sinus opacification; the modified Zinreich version scores each sinus 0–5 (percent opacification) with ostiomeatal complex 0–2, total maximum 54.

UseUsed to objectively assess disease extent preoperatively and referenced by guidelines to guide surgical decisions.

PerformanceStudies show computerized volumetric methods may be more sensitive to change; Lund-Mackay has moderate agreement with volumetric assessments.

inv-57: Balloon sinus dilation vs functional endoscopic sinus surgery

Comparative contextEvidence from systematic reviews, RCTs, and guideline assessments indicates BSD can have similar short-term efficacy to FESS in selected patients, with faster recovery in some studies (e.g., NICE for XprESS), but long-term superiority is not established.

Selection importancePatient selection and objective confirmation of disease determine appropriateness; BSD not a universal substitute for FESS.

Evidence limitationsStudies vary in design and quality; some devices (self-expanding absorptive) lack sufficient comparative evidence.