CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Sinus Surgeries (FESS, Sinuplasty, Septoplasty) and Propel® steroid nasal stent

Clinical review criteria governing medical necessity determinations for Functional Endoscopic Sinus Surgery (FESS), balloon sinuplasty, septoplasty (with/without turbinate procedures), and coverage for the Propel® drug-eluting steroid nasal stent for Kaiser Permanente Washington members.

Policy Summary

PayerKaiser Permanente

PolicySinus Surgeries — FESS, Sinuplasty, Septoplasty, Propel®

Policy CodePolicy N/A

Change TypeAdoption of MCG criterianew septoplasty criteriaPropel moved to sinus policy

Effective DateN/A

Next Review DateNov 4, 2025

Key ActionSubmit prior authorization with last 6 months of clinical notes and obtain prior authorization for listed FESS, sinuplasty, septoplasty, and Propel® codes per the applicable criteria.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt new criteria Functional Endoscopic Sinus Surgery (FESS), MCG A-0185 and Sinuplasty, MCG A-0478; requires 60-day notice, effective February 1, 2024.

MPC approved new hybrid Septoplasty criteria, KP-0812 12012025; 60-day notice required, effective 12/01/2025.

Moved Propel code from Medically necessary services policy to Sinus surgery policy and adopted medical necessity criteria for Propel; effective April 1, 2026.

3surgical categories covered

31237-31288; 31295-31298; 30520; C2625; S1091example codes listed

18+Propel age requirement

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Coverage Criteria — Sinus Procedures & Propel®

Drug-Eluting Steroid Nasal Stent (Propel®)

Drug-Eluting Steroid Nasal Stent (Propel®) — Covered when ALL of the following are met:

ALL of the following

Member is 18 years or older.
Member meets medical necessity criteria for Functional Endoscopic Sinus Surgery (FESS) as defined by the applicable MCG guideline adopted by Kaiser Permanente (MCG A-0185) or applicable policy statements.
Use is for the intended temporary non-coronary nasal stent indication (Propel®).

Coding and plan notes

Propel® HCPCS/CPT/other codes may apply (e.g., S1091 or C2625 as applicable by plan and effective date).
For Medicare members, coverage follows criteria in the applicable Medicare policy statements.
Verification of authorization requirements should be performed using the Pre-authorization Code Check for the specific plan type.

Operational notes

Codes listed may not be all-inclusive; deleted or out-of-effect codes may not be covered.
Provider should confirm current valid codes and authorization requirements.
Propel® coverage and coding may be subject to the same-day surgical bundling rules (e.g., sinuplasty not separately reimbursed when billed with FESS by same provider on same date of service).
See Kaiser Permanente payment policy for reimbursement clarifications.

Procedure, Device, and Diagnosis Codes

Covered CPT Codes — Functional Endoscopic Sinus Surgery (FESS)CPTCovered

31237	Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure).
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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Covered CPT Codes — SinuplastyCPTCovered

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

Covered CPT Codes — SeptoplastyCPTCovered

30520

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft.

Covered HCPCS/HCPC-S Codes — Propel®HCPCSCovered

C2625	Stent, non-coronary, temporary, with delivery system.
S1091	Stent, noncoronary, temporary, with delivery system (Propel) (effective 4/1/2021).

ICD-10 Codes referenced for Propel®ICD-10

J01.00	Acute maxillary sinusitis, unspecified.
J01.01	Acute recurrent maxillary sinusitis.
J01.90	Acute sinusitis, unspecified.
J01.91	Acute recurrent sinusitis, unspecified.
J32.0	Chronic maxillary sinusitis.
J32.1	Chronic frontal sinusitis.
J32.2	Chronic ethmoidal sinusitis.
J32.4	Chronic pansinusitis.
J32.8	Other chronic sinusitis.
J32.9	Chronic sinusitis, unspecified.

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Age for Propel®

Age requirement>= 18 years

ApplicabilityPropel® coverage requires patient to meet FESS criteria in addition to age requirement

Device codesDevice codes referenced in policy: C2625 (Medicare) and S1091 (Non‑Medicare)

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Prior authorization/medical necessity review is required for the listed endoscopic sinus surgery, sinuplasty, septoplasty procedure codes and for Propel® device codes. Submit an authorization request prior to scheduling when required by the member’s plan.

Authorization requirement applies to FESS, sinuplasty, septoplasty codes and Propel® (stent) codes — verify specific code-level requirements via the Pre-authorization Code Check.
Medicare and Non‑Medicare plan rules may differ; confirm authorization needs for the member’s plan before service.

Step Therapy

MCG Criteria & Conservative Therapy

Kaiser Permanente uses MCG Care Guidelines for medical necessity determinations: Functional Endoscopic Sinus Surgery (FESS) — MCG A-0185 and Sinuplasty — MCG A-0478 for Non‑Medicare members. Septoplasty criteria reference the applicable MCG guideline (e.g., KP-0182 / KP-0812 where noted). Prior conservative therapy steps and the specific MCG criteria must be met where applicable.

Access full MCG guideline criteria through the provider portal via the MCG Guideline Index under Quick Access.

Background and Clinical Context

Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive endoscopic technique in which sinus air cells and sinus ostia are opened using a rigid fiberoptic endoscope to treat medically refractory chronic rhinosinusitis. Sinuplasty (balloon ostial dilation) enlarges sinus ostia while preserving mucosal epithelium and may be performed in the office or operating room, depending on clinical factors. These procedures are governed by the policy’s coverage criteria, which defer to the applicable MCG care guidelines (FESS = MCG A-0185; Sinuplasty = MCG A-0478) for medical necessity determinations and related conservative-therapy steps.

Key Definitions

Functional Endoscopic Sinus Surgery (FESS)

DefinitionMinimally invasive endoscopic sinus surgery to open sinus air cells and ostia using a rigid fiberoptic endoscope

IndicationUsed for medically refractory chronic rhinosinusitis to restore ostiomeatal complex patency

Technique noteEndoscopic approach addresses sinus drainage pathways while preserving mucociliary function when possible

Sinuplasty

DefinitionBalloon ostial dilation to enlarge or open paranasal sinus outflow tracts while preserving epithelial mucosa

Procedure detailsA catheter with a balloon is inserted into the narrowed ostium and inflated under pressure to stretch mucosa and create a small bony fracture