CurrentEmblemHealthPolicy N/A

Balloon Sinuplasty (Balloon Sinus Dilation) — Coverage Criteria

Defines EmblemHealth's medical necessity criteria, coding, limitations, and documentation expectations for balloon sinus dilation (balloon sinuplasty) for members covered under EmblemHealth plans.

Policy Summary

PayerEmblemHealth

PolicyBalloon Sinuplasty (Balloon Sinus Dilation) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 12, 2025

Key ActionSubmit clinical documentation demonstrating the member meets medical necessity criteria (symptom duration, prior medical management, CT/endoscopy confirmation) for preauthorization review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12 weeksminimum symptom duration required for chronic rhinosinusitis

≥4/yrdefinition threshold for recurrent acute sinusitis (RAS)

4 codesprocedure codes listed for balloon dilation

10+ codesdiagnosis codes provided for sinusitis indications

Coverage and Medical Necessity Criteria

Policy Summary

PayerEmblemHealth

PolicyBalloon Sinuplasty (Balloon Sinus Dilation) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 12, 2025

Key ActionSubmit clinical documentation demonstrating the member meets medical necessity criteria (symptom duration, prior medical management, CT/endoscopy confirmation) for preauthorization review.

SourceLink

On This Page

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Standalone balloon sinuplasty criteria: 1) Rhinosinusitis lasting ≥ 12 weeks; 2) Persistent rhinosinusitis symptoms despite attempted medical management (examples: 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); 3) Recurrent acute sinusitis (RAS) defined as ≥ 4 episodes per year of acute bacterial rhinosinusitis (ABRS) without signs or symptoms between episodes; 4) Chronic rhinosinusitis confirmed by CT or endoscopy demonstrating one or more of: mucosal thickening; bony remodeling; bony thickening; obstruction of the ostiomeatal complex; mucopurulence; or edema; 5) Targeted sinus dilation is for the frontal, maxillary, or sphenoid sinuses.see node text

All conditions must be met for standalone coverage.

Procedure and Diagnosis Codes

Procedure Codes for balloon sinus dilationCPTCovered

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).

ICD-10 DiagnosesICD-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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Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for procedures billed with CPT codes 31295, 31296, 31297, and 31298. Requests for these services must be submitted to EmblemHealth for review prior to the scheduled service.

Affected CPT codes: 31295, 31296, 31297, 31298

Documentation Required

Required Clinical Evidence

The treating physician or primary care provider must submit clinical evidence demonstrating that the member meets the policy criteria. This documentation is required to support the medical necessity of the requested balloon sinuplasty procedure.

Required clinical evidence should include relevant history, prior treatments, imaging (CT/endoscopy) findings, and documentation of symptom duration and severity.

Step Therapy

Conservative Therapy Required Before Standalone Procedure

A documented trial of conservative medical therapy is required before performing balloon sinuplasty as a standalone procedure. Conservative measures include nasal lavage, intranasal corticosteroids or antihistamines, antibiotics if applicable, and treatment of concomitant allergic rhinitis (avoidance measures, pharmacotherapy, and/or immunotherapy when applicable).

Conservative therapy must be attempted and documented prior to standalone balloon sinuplasty.
Standalone procedure criteria require persistent symptoms despite medical management.

Documentation Required

Documentation Submission Requirement

Failure to submit the required clinical documentation will prevent proper review of preauthorization requests and post-service claim reviews and may result in denial of the request or payment.

If documentation is not received, EmblemHealth will be unable to properly review the preauthorization or post-payment claim.
Include CT/endoscopy results confirming chronic rhinosinusitis where applicable.

Background and Clinical Context

Balloon sinuplasty (balloon sinus dilation) is an endoscopic technique used to dilate sinus ostia and restore sinus drainage. It may be performed concurrently with functional endoscopic sinus surgery (FESS) as part of standard surgical management, or as a standalone procedure for selected patients who meet the policy's medical necessity criteria. Imaging confirmation (CT or endoscopy) and a documented trial of conservative medical management are required when performed as a standalone intervention.

Key Definitions

Recurrent acute sinusitis (RAS) — Definition threshold

DefinitionRecurrent acute sinusitis (RAS) defined as ≥ 4 episodes per year of acute bacterial rhinosinusitis (ABRS) without signs or symptoms of rhinosinusitis between episodes.

ContextRAS is one of the required criteria for standalone balloon sinuplasty—all listed criteria must be met.

Documentation neededClinical documentation should specify frequency and description of ABRS episodes to demonstrate ≥ 4 episodes/year.

Chronic rhinosinusitis confirmation — CT or endoscopy findings required

Confirmation requirementChronic rhinosinusitis must be confirmed by CT or endoscopy demonstrating ≥ 1 of: mucosal thickening, bony remodeling, bony thickening, obstruction of the ostiomeatal complex, mucopurulence, or edema.

Imaging modalitiesAcceptable modalities: computed tomography (CT) or nasal endoscopy per policy language.

Use in prior authSubmit CT/endoscopy findings as part of preauthorization to verify chronic rhinosinusitis criterion is met.