Premera Bluecross FESS BOD Coverage Update

Coverage Criteria for Endoscopic Sinus Surgery and Balloon Dilation

FESS - Initial Therapy

Functional endoscopic sinus surgery (FESS) is considered medically necessary when ALL of the following are met:

Duration: Chronic rhinosinusitis symptoms (e.g., mucopurulent drainage; nasal congestion/obstruction; facial pain/pressure; decreased sense of smell) have been present for at least 12 continuous weeks>= 12 weeks

See objective and therapy requirements below

Medical therapy failure: At least one 5-7 day course of oral antibiotics within the last 6 months AND topical intranasal steroids OR daily saline nasal irrigation for at least 6 consecutive weeks have been tried and failedantibiotic 5-7 days; topical 6 weeks

Document prior therapies and dates

Objective evidence: Sinus CT or MRI demonstrating significant mucosal thickening, polyps, opacification, sinus ostial obstruction, accessory ostia, or air-fluid levels OR nasal endoscopy showing purulent mucus, edema, or polyps in relevant regionsimaging or endoscopy positive

Provide imaging or endoscopy report/images

FESS - Revision Surgery

Revision FESS is considered medically necessary when ALL of the following are met:

Time since prior surgery: At least 12 weeks have passed since the previous sinus surgery>= 12 weeks

Document date of prior surgery

Symptoms: Chronic rhinosinusitis symptoms (mucopurulent drainage; nasal congestion/obstruction; facial pain/pressure; decreased sense of smell) have been present for at least 12 continuous weeks>= 12 weeks

Document symptom duration

Medical therapy since prior surgery: At least one 5-7 day course of antibiotics has been given since the previous surgery and failed to resolve symptomsantibiotic 5-7 days

Balloon Sinus Ostial Dilation (BOD)

Balloon sinus ostial dilation (BOD) is considered medically necessary when ALL of the following are met:

Duration: Chronic rhinosinusitis symptoms have been present for at least 12 continuous weeks>= 12 weeks

Document duration of symptoms

Medical therapy failure: At least one 5-7 day course of oral antibiotics AND topical intranasal steroids or daily saline nasal irrigation for at least 6 consecutive weeks have been tried and failedantibiotic 5-7 days; topical 6 weeks

Document prior therapies and dates

Objective evidence: CT or MRI showing mucosal thickening, polyps, opacification, ostial obstruction, accessory ostia, or air-fluid levels OR nasal endoscopy showing purulence, edema, or polypsimaging or endoscopy positive

BOD with FESS

Use of BOD in combination with FESS:

Concurrent use during FESS: BOD used in the same sinus cavity during FESS is considered an integral part of the FESS procedure

No separate standalone BOD criteria required when performed in the same sinus during FESS

Adjunct use: When BOD is used as an adjunct to FESS (BOD on one sinus and FESS on another during the same operation), the medical necessity criteria for BOD apply to the sinus being considered for BOD

Document which sinuses receive FESS versus BOD and the rationale

Surgical coverage criteria (FESS and BOD)

Coverage stance and clinical criteria summarized from evidence and guidelines in this document portion:

FESS coverage criteria: Covered when ALL of the following are met: (1) Diagnosis of uncomplicated CRS with objective documentation of sinonasal inflammation (anterior rhinoscopy, nasal endoscopy, or CT); (2) Symptoms persist despite maximal medical management (including saline nasal irrigation and topical intranasal corticosteroids; antibiotics and/or short-course systemic steroids as clinically indicated); (3) Patient selection based on disease-specific quality-of-life impairment where surgical intervention is appropriate.

Evidence includes RCTs and systematic reviews; FESS can improve outcomes for individuals who have failed maximal medical therapy

Balloon ostial dilation (BOD) coverage criteria: Covered with criteria when ALL of the following are met: (1) Diagnosis of CRS or RARS with objective documentation of sinonasal inflammation; (2) Failure of appropriate medical therapy (saline irrigation and topical intranasal corticosteroids at minimum); (3) BOD is requested as a standalone procedure or documented as adjunct to FESS with rationale.

REMODEL RCT demonstrated noninferiority of BOD to FESS to 24 months; large cohort complication rates reported

Coverage criteria for balloon sinus dilation

Balloon sinus ostial dilation is considered appropriate for selected patients when criteria below are met:

Imaging requirement: Pre-procedure CT scan must show evidence of sinonasal disease (e.g., ostial occlusion, mucosal thickening, or other disease correlating with symptoms)CT evidence present

CT is required before balloon dilation

Appropriate indications: Patient has symptomatic chronic rhinosinusitis without nasal polyposis, recurrent acute rhinosinusitis meeting guideline definitions, or persistent sinus disease after prior sinus surgerysymptoms + CT

AAO-HNS supports use in selected CRS/RARS patients

Device-specific considerations: For systems such as XprESS, the patient should not have severe nasal polyposis to be considered; devices used for BOD have FDA 510(k) clearance

Medical management and guideline-based sequencing

Medical management recommendations relevant to coverage decisions:

First-line therapies: Recommend saline nasal irrigation and topical intranasal corticosteroids (INCS) as first-line therapies for CRS; document trials prior to surgical considerationtrial of INCS/saline

Evidence grade A for symptom relief

Against antifungals: Topical or systemic antifungal therapy should not be prescribed for patients with CRSavoid antifungals

Recommendation against with high-quality evidence

Biologics and ATAD: Biologics may be considered (conditional) for CRSwNP and ATAD for AERD per guideline recommendations; use is conditional and should be documented when considered instead of or prior to surgeryper guideline specifics

Summary of clinical coverage criteria (refer to full policy)

Policy statements and medically necessary indications have been added and clarified over time; current excerpt documents revisions but does not restate full criteria.

Referenced changes: Policy includes medically necessary indications for recurrent acute bacterial rhinosinusitis, chronic rhinosinusitis (with or without polyposis), revision surgery, and select other diagnoses; see full policy for exact AND/OR logic and historical clarifications

History includes multiple updates to antibiotic, topical therapy, coding, and site-of-service criteria

This policy applies to adults only; it is limited to individuals aged 19 and older. Site-of-service determinations are part of the medical necessity review: the preferred outpatient locations are an Ambulatory Surgical Center (ASC) or an outpatient hospital/medical center when appropriate. Inpatient hospital/medical center admission for elective sinus procedures is considered not medically necessary when the ASC or outpatient site-of-service criteria are met or when no qualifying reason for inpatient care exists. Specific exceptions for outpatient-to-ASC conversion (for example, lack of ASC access within 30 miles, unavailable physician privileges, or other documented constraints) are described in the site-of-service section and must be documented when applicable.

The policy text for balloon ostial dilation (BOD) focuses on BOD when performed as a standalone procedure. When BOD is used in combination with functional endoscopic sinus surgery (FESS), the policy treats BOD performed in the same sinus cavity as an integral component of the FESS procedure, and when BOD is used adjunctively (for example, BOD on one sinus and FESS on another during the same operation) the medical necessity criteria for BOD must be applied to the sinus planned for BOD. Prior authorization requests should explicitly state whether BOD is being requested as a standalone intervention or as an adjunct to FESS and provide the clinical rationale.

Balloon ostial dilation and FESS are intended for individuals with objective sinonasal disease after failure of medical management. The policy requires both symptoms consistent with chronic rhinosinusitis (symptoms present for at least 12 continuous weeks) and objective confirmation of disease on sinus CT/MRI or nasal endoscopy prior to considering procedural intervention. Balloon dilation is not appropriate for individuals who lack sinonasal symptoms or do not have positive CT findings, and neither BOD nor FESS should be performed solely for headache without meeting CRS or RARS diagnostic criteria.

This medical policy does not apply to members covered under Medicare Advantage plans. Providers should consult the member’s specific benefit plan for Medicare Advantage coverage rules or refer to a plan-specific policy where applicable.

Elective sinus surgical procedures performed in an inpatient hospital/medical center are considered not medically necessary when the case meets the policy’s outpatient/ASC site-of-service criteria (for example, procedures that can safely be performed in an ASC or outpatient hospital). Providers should document the clinical justification if an inpatient setting is requested despite outpatient options.

Randomized trials and systematic reviews comparing FESS and balloon ostial dilation (BOD) show mixed results depending on the population and prior medical therapy. Some RCTs have not demonstrated superiority of FESS over maximal medical therapy for uncomplicated CRS, while the REMODEL RCT demonstrated that BOD was noninferior to FESS for selected patients, with comparable quality-of-life outcomes and durability observed through 24 months. These findings support offering BOD or FESS to appropriately selected patients after failure of guideline-directed medical therapy.

Balloon dilation is considered inappropriate for isolated headache or for treatment of sleep apnea when the individual does not meet diagnostic criteria for CRS or recurrent acute rhinosinusitis (RARS) and does not have CT evidence of sinonasal disease. Professional consensus strongly discourages using BOD for headache-only or sleep apnea-only indications absent objective sinonasal pathology.

The excerpted policy history does not reproduce every explicit 'not medically necessary' statement, but prior revisions and clarifications in the policy history emphasize the requirement for objective evidence and appropriate prior medical therapy. When a specific NMN statement is required for coverage decisions, reviewers should consult the complete policy history and full policy text for the explicit not-medically-necessary language and its effective dates.

CPT/HCPCS Coding and Key Clinical Thresholds

Covered CPT/HCPCS Codes for FESS and Balloon DilationmixedCovered

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, with or without removal of tissue from frontal sinus.
31287	Nasal/sinus endoscopy, surgical, with sphenoidotomy.
31288	Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus.

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FDA 510(k) devices listedmixed

K190525	Relieva Ultirra Sinus Balloon Catheter 510(k) number
K181838	Sinusway Dilation System 510(k) number
K172737	MESIRE Balloon Sinus Dilatation System 510(k) number
K171687	Relieva SpinPlus Nav Balloon Sinuplasty System 510(k) number
K161698	Relieva UltirraNav Sinus Balloon Catheter 510(k) number
K160770	Vent-Os Sinus Dilation Family 510(k) number
K153341	Relieva Scout Multi-Sinus Dilation System 510(k) number
K152434	XprESS Multi-Sinus Dilation System 510(k) number
K143738	DSS Sinusplasty Balloon Catheter 510(k) number
K143541	Relieva SpinPlus Balloon Sinuplasty System 510(k) number

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Coding updates and affected CPT/HCPCS codesmixed

31233	CPT code added to policy May 2025 (later removed)
31235	CPT code added to policy May 2025 (later removed)
31240	CPT code added to policy May 2025 (later removed)
31241	CPT code added January 1, 2018 (mentioned in coding update history)
31253	CPT code added January 1, 2018 (mentioned in coding update history)
31257	CPT code added January 1, 2018 (mentioned in coding update history)
31259	CPT code added January 1, 2018 (mentioned in coding update history)
31295	CPT code descriptor revised January 1, 2020
31296	CPT code descriptor revised January 1, 2020
31297	CPT code descriptor revised January 1, 2020

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inv-20: Chronic rhinosinusitis duration — key threshold value

Chronic rhinosinusitis duration>= 12 continuous weeks

ContextSymptoms include mucopurulent drainage, nasal congestion/obstruction, facial pain/pressure, decreased sense of smell

Documentation noteProviders should document ≥12 weeks of symptoms for CRS diagnosis (see imaging/endoscopy requirements)

inv-21: Oral antibiotic course — required duration as a key value

Required oral antibiotic course (current)At least one 5–7 day course within the last 6 months

Documentation context

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for elective outpatient sinus surgery and for procedures performed outside a covered site-of-service. Providers must obtain site-of-service pre-approval before scheduling elective sinus surgery in non-hospital outpatient settings.

Elective sinus surgery performed outside a covered site-of-service (e.g., certain offices) may be noncovered without prior approval.
Confirm the planned site (ASC, on-campus outpatient HOPD, off-campus outpatient HOPD, inpatient) and obtain authorization if the procedure is not in the preferred site.

Documentation Required

Document Symptom Onset, Duration, and Failed Medical Therapy for CRS

For chronic rhinosinusitis (CRS) cases, the medical record must document symptom onset and duration and evidence that maximal medical therapy was tried and failed before surgery is authorized.

Document onset and duration of sinonasal symptoms (e.g., mucopurulent drainage, nasal congestion/obstruction, facial pain/pressure, decreased sense of smell) — symptoms should be present for ≥12 continuous weeks for CRS.

Background and Evidence Summary

Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses and nasal mucosa that persists for at least 12 weeks. Typical clinical features include mucopurulent nasal drainage, nasal obstruction or congestion, facial pain or pressure, and reduced or lost sense of smell. Standard initial management is maximal medical therapy, including saline nasal irrigation and topical intranasal corticosteroids; short-course systemic antibiotics or corticosteroids are used when clinically indicated. Objective confirmation of sinonasal inflammation—by anterior rhinoscopy, nasal endoscopy, or CT/MRI demonstrating mucosal thickening, ostial obstruction, air–fluid levels, or polyps—is required before proceeding with BOD or FESS.

Definitions and Terminology

inv-43: Recurrent acute rhinosinusitis definition — 4+ episodes/year threshold

RARS episode thresholdFour or more acute episodes of acute bacterial rhinosinusitis within 12 continuous months

Inter-episode symptom requirementDefined as recurrent acute bacterial rhinosinusitis without persistent symptoms between episodes

Medical therapy requirementPolicy notes at least one 5–7 day antibiotic course within last 6 months as part of medical therapy for RARS consideration

inv-44: Chronic rhinosinusitis (CRS) definition — symptoms >12 weeks and required symptom set/objective evidence

CRS duration definitionSymptoms lasting more than (or at least) 12 weeks

Required symptom setAt least two symptoms, one of which must be nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior); may include facial pain/pressure and reduced sense of smell

OpenPayer

Endoscopic sinus surgery and balloon sinus ostial dilation (BOD) coverage

Coverage Criteria for Endoscopic Sinus Surgery and Balloon Dilation

CPT/HCPCS Coding and Key Clinical Thresholds

Prior Authorization and Documentation Requirements

Background and Evidence Summary

Definitions and Terminology