Premera Bluecross FESS & BOD Coverage Update

Coverage Criteria for Sinus Procedures

Functional endoscopic sinus surgery (FESS) — recurrent acute bacterial rhinosinusitis

Covered when ALL of the following are met

Recurrent acute bacterial rhinosinusitis criteria: Four or more documented episodes of acute bacterial rhinosinusitis within 12 continuous months AND prior medical therapy tried and failed (at least one 5-7 day oral antibiotic within the last 6 months AND topical intranasal steroids OR daily saline nasal irrigation for at least 4 consecutive weeks) AND objective evidence of sinus disease by CT/MRI or nasal endoscopy.4+ episodes/12 months; antibiotic 5-7 days; topical therapy 4 weeks

Objective evidence may include CT/MRI showing mucosal thickening, polyps, opacification, ostial obstruction, or air-fluid levels, or nasal endoscopy showing purulence, edema, or polyps.

Functional endoscopic sinus surgery (FESS) — chronic rhinosinusitis

Covered when ALL of the following are met

Chronic rhinosinusitis criteria: Symptoms present for at least 12 continuous weeks AND prior medical therapy tried and failed (at least one 5-7 day course of antibiotics within the last 6 months AND topical intranasal steroids OR daily saline nasal irrigation for at least 6 consecutive weeks) AND objective evidence of sinus disease by CT/MRI or nasal endoscopy.≥12 weeks; antibiotic 5-7 days; topical therapy 6 weeks

Objective evidence may include CT/MRI showing mucosal thickening, polyps, opacification, ostial obstruction, or air-fluid levels, or nasal endoscopy showing purulent mucus or edema or polyps. Surgery may be unilateral or bilateral depending on findings.

Revision Functional Endoscopic Sinus Surgery

Covered when ALL of the following are met

Revision surgery criteria: At least 12 weeks have passed since the previous sinus surgery AND chronic rhinosinusitis symptoms for at least 12 continuous weeks AND prior medical therapy tried and failed (at least one 5-7 day course of antibiotics since the previous surgery) AND persistent objective evidence of sinus disease by CT/MRI or nasal endoscopy.≥12 weeks since prior surgery; symptoms ≥12 weeks

Documentation must show persistent disease amenable to surgical treatment; applies to revision FESS procedures.

Balloon sinus ostial dilation (BOD)

Covered when ALL of the following are met

BOD criteria: Chronic rhinosinusitis symptoms present for at least 12 continuous weeks AND prior medical therapy tried and failed (at least one 5-7 day course of antibiotics AND topical intranasal steroids OR daily saline nasal irrigation for at least 6 consecutive weeks) AND objective evidence of sinus disease by CT/MRI or nasal endoscopy.≥12 weeks; antibiotic 5-7 days; topical therapy 6 weeks

BOD can be performed as a standalone procedure or adjunctively to FESS; when used adjunctively the policy is limited to standalone BOD for coverage determinations and BOD used adjunctively is considered part of the FESS procedure or addressed separately.

Specific indications for FESS

Covered diagnoses (any of the following makes FESS medically necessary when appropriate):

Covered diagnoses for FESS: Multiple nasal polyps; cerebrospinal fluid (CSF) leak closure; choanal atresia repair; dacryocystorhinostomy (DCR); epistaxis control; excision of selected tumors and nasal masses; foreign body removal; optic nerve decompression; orbital decompression (e.g., Graves disease); recurrent sinusitis in people with cystic fibrosis or severe asthma; silent sinus syndrome confirmed by CT; sinus mucoceles; sinus disease eroding into bone; sinus disease in the immunocompromised; invasive fungal sinus disease; allergic fungal sinus disease; sinus disease related to Wegener's granulomatosis; hereditary hemorrhagic telangiectasia; sinus disease related to scarring or osteoneogenetic changes.

List extracted directly from policy.

Site-of-service medical necessity

Site of service determined by medical necessity rules

Medically necessary sites: Ambulatory Surgical Center (preferred) OR Off‑campus outpatient hospital/medical center OR On‑campus outpatient hospital/medical center when no ASC within 30 miles or an ASC lacks necessary equipment or physician privileges, or the individual is ≤18 years old, or the procedure is in conjunction with an additional service that requires a hospital outpatient department, or the patient has increased clinical risk (e.g., ASA III+, significant cardiac, pulmonary, hepatic, renal risks, morbid obesity, pregnancy, bleeding disorder, anticipated transfusion need).ASC within 30 miles availability criteria; ASA III+ etc.

Inpatient hospital/medical center is considered NOT medically necessary for these elective procedures when site‑of‑service criteria are not met.

FESS — coverage when criteria met — Covered when ALL of the following are met

Covered when ALL of the following are met

FESS coverage criteria: 1) Diagnostic criteria for chronic rhinosinusitis or recurrent acute rhinosinusitis are met with objective documentation of sinonasal inflammation (endoscopy, rhinoscopy, or CT). 2) The individual has failed maximal medical management (e.g., saline irrigation, topical intranasal corticosteroids, and appropriate systemic therapies/antibiotics when indicated). 3) The procedure is intended to improve sinus ventilation/drainage, remove obstructing polyps/debris, or correct structural problems contributing to disease.

FESS is appropriate for individuals who meet diagnostic criteria and have failed maximal medical management; evidence supports improved outcomes in this population.

Balloon ostial dilation (BOD) — coverage when criteria met — Covered with criteria when used as a standalone procedure

Covered with criteria when used as a standalone procedure

BOD coverage criteria: 1) Diagnostic criteria for chronic rhinosinusitis or recurrent acute rhinosinusitis are met with objective documentation of sinonasal inflammation. 2) The individual has failed appropriate medical management (maximal medical therapy). 3) BOD is being used as a standalone procedure.

Evidence (including the REMODEL RCT) demonstrates non‑inferiority of standalone BOD to FESS for uncomplicated CRS with durability to 24 months; policy is limited to BOD when used as a standalone procedure for coverage determinations.

Balloon ostial dilation (BOD) — Covered when selection criteria are met

Balloon sinus ostial dilation is considered a therapeutic option for selected patients when ALL of the following are met:

Imaging and symptoms: Patient has sinonasal symptoms AND CT findings consistent with sinonasal disease.CT required

AAO‑HNS and NICE guidance state CT scanning is required before balloon dilation.

Appropriate indication: Indication is chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS); not for isolated headache or sleep apnea without CRS/RARS.symptom‑based

Balloon dilation inappropriate for headache or sleep apnea without CRS/RARS (strong consensus).

Prior therapy or prior surgery: Patient has failed appropriate medical therapy (e.g., saline irrigation, topical intranasal corticosteroids) OR has persistent disease after prior sinus surgery.

Elective sinus surgical procedures performed in an inpatient hospital/medical center are considered NOT medically necessary when the policy's site-of-service medical necessity criteria are not met. The policy lists preferred outpatient sites (e.g., an Ambulatory Surgical Center) and specifies clinical and site availability circumstances that must be met for higher-acuity settings; absent those criteria, inpatient care for these elective procedures is not covered.

This policy addresses balloon ostial dilation (BOD) when it is performed as a standalone procedure. The policy explicitly limits coverage language to standalone BOD and does not set a coverage position for BOD when used adjunctively with FESS; when used during FESS the device or dilation may be considered part of the overall endoscopic procedure rather than a separate standalone intervention.

Balloon dilation is considered inappropriate for individuals who lack sinonasal symptoms or who have a sinus CT that does not show evidence of sinonasal disease. The policy and referenced society guidance require both symptomatic disease and CT-confirmed findings (e.g., mucosal thickening, ostial occlusion) before balloon dilation is considered.

Within the provided document chunks there are no additional explicit clinical exclusion statements beyond those summarized elsewhere. The policy history entries record multiple edits, clarifications, and additions to documentation and coding, but do not introduce specific new clinical exclusion criteria in the selected excerpts.

Elective sinus surgical procedures performed in a site of service that does not meet the policy's medical necessity criteria (for example, inpatient hospital/medical center when outpatient ASC or outpatient hospital criteria are not met) are considered not medically necessary under this policy.

Procedures (FESS or standalone BOD) performed in individuals who have not failed maximal medical management or who lack objective documentation of chronic rhinosinusitis are not covered. The policy requires documentation of failed medical therapy (e.g., nasal irrigation and topical intranasal corticosteroids, and when indicated systemic antibiotics) and objective confirmation of sinonasal inflammation by CT, MRI, or nasal endoscopy before surgical coverage is appropriate.

Use of balloon dilation in patients lacking both symptoms and CT findings of sinonasal disease, or for indications such as isolated headache or sleep apnea without CRS/RARS, is considered inappropriate. Society guidance and NICE recommendations emphasize that balloon dilation is indicated for symptomatic CRS or recurrent acute rhinosinusitis with CT evidence of disease, not for unrelated complaints.

The policy history documents multiple edits, coding updates, and clarifications over time; however, in the selected chunks there are no standalone not-medically-necessary statements beyond those already summarized (site-of-service and lack of required medical therapy or objective findings). Historical entries primarily record administrative and coding changes and clarifications to documentation requirements.

Coding and Device Clearances

Relevant CPT and HCPCS codesmixed

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) device clearances (listed)mixed

K190525	Relieva Ultirra Sinus Balloon Catheter 510(k) No.
K181838	Sinusway Dilation System 510(k) No.
K172737	MESIRE - Balloon Sinus Dilatation System 510(k) No.
K171687	Relieva SpinPlus Nav Balloon Sinuplasty System 510(k) No.
K161698	Relieva UltirraNav Sinus Balloon Catheter 510(k) No.
K153341	Relieva Scout Multi-Sinus Dilation System 510(k) No.
K152434	XprESS Multi-Sinus Dilation System 510(k) No.
K143738	DSS Sinusplasty Balloon Catheter 510(k) No.
K143541	Relieva SpinPlus Balloon Sinuplasty System 510(k) No.
K142252	XprESS Multi-Sinus Dilation Tool 510(k) No.

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Policy-mentioned CPT/HCPCS codes with historical changesmixed

31295	CPT descriptor revised (per history entry)
31296	CPT descriptor revised (per history entry)
31297	CPT descriptor revised (per history entry)
31298	CPT descriptor revised (per history entry)
31233	Added to policy (05/01/25) then removed (08/01/25)
31235	Added to policy (05/01/25) then removed (08/01/25)
31240	Added to policy (05/01/25) then removed (08/01/25)
C1726	HCPCS code added (11/01/20)

Symptom duration and prior therapy thresholds

Chronic CRS symptom durationSymptoms present for at least 12 continuous weeks (≥12 weeks)

Recurrent acute rhinosinusitis thresholdFour or more documented acute bacterial rhinosinusitis episodes within 12 continuous months (4+ episodes/12 months)

Required prior oral antibioticAt least one 5–7 day course of oral antibiotics within the last 6 months

Required prior topical therapyTopical intranasal steroids OR daily saline nasal irrigation for at least 6 consecutive weeks (some indications note 4 weeks)

Provider Actions, Prior Authorization, and Documentation

Denial Risk

Site-of-service noncompliance

Sinus surgery performed outside a hospital operating room requires health plan pre-approval. Elective sinus surgical procedures performed in a non-medically necessary site of service (for example, when site-of-service rules favor an ambulatory surgical center but the procedure is done in a hospital outpatient department without documented exception) may be denied or be subject to member cost-sharing. Verify and document the medically appropriate site of service when submitting prior authorization and claims.

Check site-of-service rules before scheduling elective sinus procedures.
If hospital outpatient department is used, document why ASC is not available or why hospital setting is necessary (no ASC within 30 miles with necessary equipment or physician privileges; patient's age ≤18; concurrent service requiring hospital department; or clinical conditions increasing risk).

Denial Risk

Insufficient prior medical therapy

Prior authorization review requires documentation that the individual has tried and failed required medical therapy prior to FESS or balloon ostial dilation (BOD). Procedures performed without documentation of these required therapies may be denied.

Definitions and Procedure Descriptions

Chronic rhinosinusitis

DefinitionChronic rhinosinusitis: Symptoms present for ≥12 weeks with two or more symptoms (one must be nasal obstruction or nasal discharge) plus objective evidence of inflammation on endoscopy or CT (e.g., mucopurulence, edema, polyps, mucosal thickening, or air-fluid levels)

Required objective evidenceSinus CT or MRI showing mucosal thickening, polyps, opacification, ostial obstruction, or air-fluid levels OR nasal endoscopy showing purulent mucus or edema in middle meatus/ethmoid/sphenoethmoid regions or visible polyps

Typical symptomsMucopurulent drainage, nasal congestion/obstruction, facial pain/pressure, decreased sense of smell

Recurrent acute rhinosinusitis

DefinitionRecurrent acute rhinosinusitis: Four or more acute episodes of acute bacterial rhinosinusitis within 12 months without persistent symptoms between episodes

Evidence, Epidemiology, and Procedural Context

CRS affects a notable portion of adults and contributes substantially to procedural volumes (e.g., approximately 350,000 FESS procedures annually in the U.S.). Management begins with maximal medical therapy—saline irrigation and topical intranasal corticosteroids, with systemic antibiotics when indicated—and progresses to procedural interventions for patients who fail adequate medical management. Balloon dilation devices are FDA-cleared and can offer shorter recovery in selected uncomplicated cases; evidence synthesis and guidance (AAO‑HNS, NICE) support use of BOD in appropriately selected, symptomatic patients with CT-confirmed disease.

Policy Revision History

2014-12-08policy_created

New policy created and added to the Surgery section; held for provider notification with planned future effective date.

2015-03-20implementation_delay

Implementation delayed (multiple subsequent delays recorded) from original planned effective date toward July–December 2015.

2015-09-08interim_review

Interim review: expanded definitions for acute, subacute and chronic rhinosinusitis; clarified maximal medical therapy and refined policy statements to distinguish recurrent acute bacterial rhinosinusitis and chronic rhinosinusitis; policy effective Jan 1, 2016.

OpenPayer

Endoscopic sinus surgery and balloon sinus ostial dilation (FESS & BOD) — coverage criteria

Coverage Criteria for Sinus Procedures

Coding and Device Clearances

Provider Actions, Prior Authorization, and Documentation

Definitions and Procedure Descriptions

Evidence, Epidemiology, and Procedural Context

Policy Revision History