Clinical Review Criteria — Sinus Surgeries: Sinuplasty, Functional Endoscopic Sinus Surgery (FESS), Septoplasty
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Clinical review criteria governing medical necessity determinations and preauthorization requirements for sinuplasty, FESS, and septoplasty for Kaiser Foundation Health Plan of Washington members and their providers.
Kaiser Permanente adopted MCG Care Guideline A-0185 for FESS and A-0478 for sinuplasty to determine medical necessity.
New hybrid Septoplasty criteria (KP-0812 12012025) were approved, effective December 1, 2025, requiring level-of-care review and MCG criteria.
Sinuplasty will not be separately reimbursed when billed with FESS by the same provider on the same date of service.
Coverage and Medical Necessity Criteria
Medical necessity criteria by procedure
Considered medically necessary when the applicable MCG or Kaiser criteria are met for the member's plan type:
Access to the MCG Guideline Index via the provider portal or request a copy from Clinical Review staff.
Refer to the Kaiser Permanente payment policy portal for reimbursement clarifications (Sinuplasty billed with FESS).
MCG criteria are proprietary; a copy may be requested from Kaiser Permanente Clinical Review staff.
Kaiser Permanente will not separately reimburse sinuplasty when it is billed with a Functional Endoscopic Sinus Surgery (FESS) procedure for the same member on the same date of service by the same provider. Refer to the Kaiser Permanente payment policy portal for specific reimbursement clarifications and bundling details.
Procedures that do not meet the applicable MCG or Kaiser criteria are considered not medically necessary. Medical necessity determinations follow the criteria in the applicable policy statements and referenced MCG clinical guidelines; codes that do not meet those criteria may be denied.
Procedure Codes
| 31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) |
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total anterior and posterior |
| 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; (frontal sinus exploration variant) |
| 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 |
| 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); (unspecified) |
| 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 |
| 30520 | Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft |
Provider Requirements and Billing Rules
Prior Authorization Required
Prior authorization is required for the listed CPT codes when those codes are subject to applicable medical necessity criteria. Verify specific preauthorization requirements for the member's plan and use the Pre-authorization Code Check to confirm whether an authorization is needed for a given code.
- Verify authorization requirements by plan using the Pre-authorization Code Check
- Authorization required when codes are subject to applicable medical necessity criteria
Guideline-based Requirement
Kaiser Permanente uses MCG clinical guidelines for stepwise medical necessity determinations for Functional Endoscopic Sinus Surgery (FESS), sinuplasty, and septoplasty. Refer to the applicable MCG guideline (e.g., FESS A-0185, Sinuplasty A-0478, Septoplasty KP-0182/KP-0812) via the provider portal Quick Access for the specific criteria that must be met.
- FESS — MCG A-0185
- Sinuplasty — MCG A-0478
- Septoplasty — MCG KP-0182 / KP-0812 (effective dates per guideline)
Required Documentation
Submit clinical documentation to support medical necessity at the time of the request. Include the last 6 months of clinical notes from the requesting provider and/or specialist.
- Last 6 months of clinical notes from requesting provider and/or specialist
Bundling / Reimbursement Risk
Reimbursement may be denied when sinuplasty is billed separately with FESS by the same provider on the same date of service; refer to the Kaiser Permanente payment policy for reimbursement clarifications.
- Sinuplasty billed with FESS by same provider on same DOS may be denied for separate reimbursement
- See Sinuplasty Billed with Functional Endoscopic Sinus Surgery (FESS) payment policy for details
Clinical Background
Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive endoscopic approach used to restore sinus drainage in patients with medically refractory chronic rhinosinusitis by addressing patency of the ostia and sinus air cells. Kaiser Permanente has adopted the MCG Care Guideline A-0185 for FESS medical necessity determinations; see the provider portal for access to the guideline and related policy statements.
Procedure Definitions
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