CurrentConnectiCarePolicy MG.MM.ME.26

Balloon Sinuplasty

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This policy governs ConnectiCare coverage and prior authorization for balloon sinuplasty, including use with functional endoscopic sinus surgery (FESS) and as a stand-alone procedure. It applies to providers submitting clinical evidence for medical-necessity review; member benefit-plan terms may further limit coverage.

Policy Summary

PayerConnectiCare

PolicyBalloon Sinuplasty

Policy CodePolicy MG.MM.ME.26

Change TypeCoverage criteria clarification

Effective DateSep 11, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

The policy clarified on March 10, 2023 that balloon sinuplasty is medically necessary when performed with FESS.

Endoscopy was added as a confirmation modality for chronic rhinosinusitis on September 10, 2021.

Recurrent acute sinusitis was added as a covered indication and endoscopy was removed as an evaluation option on August 14, 2020.

≥12 weeksRequired duration of rhinosinusitis for stand-alone treatment

≥4/yearAcute bacterial rhinosinusitis episodes defining recurrent acute sinusitis

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CurrentConnectiCarePolicy MG.MM.ME.26

Balloon Sinuplasty

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Policy Summary

PayerConnectiCare

PolicyBalloon Sinuplasty

Policy CodePolicy MG.MM.ME.26

Change TypeCoverage criteria clarification

Effective DateSep 11, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria when requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

The policy clarified on March 10, 2023 that balloon sinuplasty is medically necessary when performed with FESS.

Endoscopy was added as a confirmation modality for chronic rhinosinusitis on September 10, 2021.

Recurrent acute sinusitis was added as a covered indication and endoscopy was removed as an evaluation option on August 14, 2020.

≥12 weeksRequired duration of rhinosinusitis for stand-alone treatment

≥4/yearAcute bacterial rhinosinusitis episodes defining recurrent acute sinusitis

Medical Necessity and Coverage Criteria

Balloon Sinuplasty With FESS

Covered when performed along with functional endoscopic sinus surgery (FESS).

Balloon sinuplasty with FESS: Balloon sinuplasty is medically necessary when performed along with a functional endoscopic sinus surgery (FESS).

No additional stand-alone criteria apply when balloon sinuplasty is performed with FESS.

Stand-Alone Balloon Sinuplasty

Stand-alone balloon sinuplasty is covered when all of the following criteria are met.

Stand-alone medical necessity

Clinical history and treatment response: Rhinosinusitis has lasted at least 12 weeks, and symptoms persist despite attempted medical management.Rhinosinusitis ≥ 12 weeks
Attempted medical management may include nasal lavage, intranasal corticosteroids or antihistamines, antibiotics if applicable, and/or treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy if applicable.
Recurrent acute sinusitis: The patient has recurrent acute sinusitis (RAS).≥ 4 episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes
Objective confirmation of chronic rhinosinusitis
- Mucosal thickening
- Bony remodeling
- Bony thickening
- Obstruction of the ostiomeatal complex
- Edema
- Mucopurulence
  Qualifying endoscopy finding.
Eligible sinus location: Sinus dilation is for the frontal, maxillary, or sphenoid sinuses.Frontal, maxillary, or sphenoid sinus

Balloon sinus dilation is considered experimental/investigational for all other indications, including nasal polyps or tumors.

Procedure and Diagnosis Coding

Covered CPT CodesCPTCovered

31295	Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa.
31296	Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation).
31297	Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation).
31298	Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg balloon dilation).

Diagnosis CodesICD-10

J01.00	Acute maxillary sinusitis, unspecified.
J01.01	Acute recurrent maxillary sinusitis.
J01.10	Acute frontal sinusitis, unspecified.
J01.11	Acute recurrent frontal sinusitis.
J01.30	Acute sphenoidal sinusitis, unspecified.
J01.31	Acute recurrent sphenoidal sinusitis.
J01.40	Acute pansinusitis, unspecified.
J01.41	Acute recurrent pansinusitis.
J01.80	Other acute sinusitis.
J01.81	Other acute recurrent sinusitis.

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Rhinosinusitis Duration

Required durationAt least 12 weeks

ConditionRhinosinusitis

ApplicationRequired for stand-alone balloon sinuplasty

Recurrent Acute Sinusitis Frequency

Minimum frequencyAt least 4 episodes per year

Episode typeAcute bacterial rhinosinusitis (ABRS)

Between episodes

Prior Authorization and Documentation

Prior Authorization

Clinical Evidence Required for Prior Authorization

Clinical evidence is required for prior authorization. The treating physician or primary care provider must submit clinical evidence demonstrating that the patient meets ConnectiCare’s applicable medical-necessity criteria for balloon sinuplasty or the surgical procedure. Without this documentation, ConnectiCare cannot properly review the request.

Submit clinical evidence demonstrating that the patient meets the applicable treatment or procedure criteria.
Coverage may differ for Medicare members based on applicable CMS coverage statements, including NCDs, LCDs, and/or LMRPs.

Documentation Required

Provider Must Submit Supporting Evidence

The treating physician or primary care provider is responsible for submitting the supporting clinical evidence and information to ConnectiCare with the prior authorization request.

Procedure Overview

Balloon sinuplasty is an endoscopic sinus procedure that uses a balloon device to dilate selected sinus ostia. The policy considers it medically necessary when performed with functional endoscopic sinus surgery (FESS) and permits stand-alone use for specified persistent or recurrent rhinosinusitis when objective CT or endoscopic findings support chronic rhinosinusitis. Dilation is limited to the frontal, maxillary, or sphenoid sinuses.

Clinical Definitions

Recurrent Acute Sinusitis (RAS)

DefinitionAt least 4 episodes per year of acute bacterial rhinosinusitis

Symptom-free intervalNo signs or symptoms of rhinosinusitis between episodes

AbbreviationRAS (recurrent acute sinusitis)

Chronic Rhinosinusitis Confirmation

Confirmation methodCT or endoscopy scan findings

Minimum objective evidenceAt least 1 finding

Qualifying findingsMucosal thickening; bony remodeling; bony thickening; obstruction of the ostiomeatal complex; edema; or mucopurulence

Documentation Required

Document Medical Necessity

For stand-alone balloon sinuplasty, document that all medical-necessity criteria are met: rhinosinusitis lasting at least 12 weeks; persistent symptoms despite attempted medical management; recurrent acute sinusitis defined as at least 4 episodes per year of acute bacterial rhinosinusitis without symptoms between episodes; and objective CT or endoscopy findings confirming chronic rhinosinusitis.

Document the duration of rhinosinusitis: ≥ 12 weeks.
Document persistent symptoms despite attempted medical management, such as nasal lavage, intranasal corticosteroids or antihistamines, antibiotics when applicable, and treatment of concomitant allergic rhinitis when applicable, including avoidance measures, pharmacotherapy, and/or immunotherapy.
Document recurrent acute sinusitis (RAS): ≥ 4 episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes.
Include CT or endoscopy findings showing at least one of the following: mucosal thickening, bony remodeling, bony thickening, ostiomeatal-complex obstruction, or edema.