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CurrentPremera Blue Cross of WashingtonPolicy N/A

Adult Sinus Surgery Coverage

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Coverage criteria, prior authorization, site-of-service review, documentation, and coding requirements for elective sinus surgery in individuals aged 19 and older, including FESS, revision FESS, and balloon sinus ostial dilation.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyAdult Sinus Surgery Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewOct 14, 2026

Next Review DateN/A

Key ActionBefore balloon sinus ostial dilation, obtain CT imaging and document sinonasal symptoms with positive CT findings demonstrating sinonasal disease.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19+Minimum age

12 weeksChronic symptom duration

4+ episodesRecurrent acute threshold

5–7 daysRequired antibiotic course

31253–31298Listed procedure code range

Medical Necessity and Site-of-Service Criteria

FESS for recurrent acute bacterial rhinosinusitis

FESS may be considered medically necessary when all criteria are met.

Recurrent acute bacterial rhinosinusitis

Objective evidence: Sinus CT or MRI showing significant mucosal thickening, polyps, paranasal sinus opacification, sinus ostial obstruction, or air-fluid levels; OR nasal endoscopy showing purulent mucus or edema in the middle meatus, anterior ethmoid region, or sphenoethmoid region, or polyps in the nasal cavity or middle meatus.One objective modality
Surgery may be unilateral or bilateral depending on symptoms and imaging findings.

FESS for chronic rhinosinusitis

FESS may be considered medically necessary when all criteria are met.

Chronic rhinosinusitis with or without polyposis

Policy Summary

PayerPremera Blue Cross of Washington

PolicyAdult Sinus Surgery Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2026

Last ReviewOct 14, 2026

Next Review DateN/A

Key ActionBefore balloon sinus ostial dilation, obtain CT imaging and document sinonasal symptoms with positive CT findings demonstrating sinonasal disease.

SourceLink

On This Page

Objective evidence: Sinus CT or MRI showing significant mucosal thickening, polyps, paranasal sinus opacification, sinus ostial obstruction, maxillary accessory ostium or ostia/ostiomeatal complex, presence of accessory ostia, or air-fluid levels; OR nasal endoscopy showing purulent mucus or edema in the middle meatus, anterior ethmoid region, or sphenoethmoid region, or polyps in the nasal cavity or middle meatus.One objective modality

Revision FESS

Revision FESS may be considered medically necessary when all criteria are met.

Revision surgery

Persistent objective evidence: Sinus CT or MRI showing significant mucosal thickening, polyps, paranasal sinus opacification, sinus ostial obstruction, or air-fluid levels; OR nasal endoscopy showing purulent mucus or edema in the middle meatus, anterior ethmoid region, or sphenoethmoid region, or polyps in the nasal cavity or middle meatus.One objective modality

Diagnoses supporting medically necessary FESS

FESS may be considered medically necessary when one of the following diagnoses is present.

Diagnoses considered medically necessary for FESS: Abscess as a complication of sinusitis; cerebrospinal fluid leak closure; choanal atresia repair; symptomatic concha bullosa; dacryocystorhinostomy; epistaxis control; excision of selected tumors and nasal masses; foreign body removal; multiple nasal polyps (antrochoanal polyps); optic nerve decompression; orbital decompression such as for Graves ophthalmopathy; recurrent sinusitis in a person with cystic fibrosis or severe asthma; silent sinus syndrome or Stage III chronic maxillary atelectasis confirmed by paranasal sinus CT; sinonasal tumor; symptomatic sinus mucocele; sinus disease eroded into bone; sinus disease in an immunocompromised person; invasive fungal sinus disease; allergic fungal sinus disease; sinus disease related to Wegener's granulomatosis; or sinus disease related to hereditary hemorrhagic telangiectasia.One listed diagnosis

This diagnostic pathway is separate from the chronic or recurrent rhinosinusitis criteria.

Balloon sinus ostial dilation

Balloon sinus ostial dilation may be considered medically necessary when all criteria are met.

Objective evidence: Sinus CT or MRI showing significant mucosal thickening, polyps, paranasal sinus opacification, sinus ostial obstruction, maxillary accessory ostium or ostia/ostiomeatal complex, presence of accessory ostia, or air-fluid levels; OR nasal endoscopy showing purulent mucus or edema in the middle meatus or anterior ethmoid region.One objective modality
The policy text continues the nasal-endoscopy criteria beyond the cited excerpt.

FESS for refractory chronic rhinosinusitis

FESS may be appropriate when all of the following are met.

FESS for chronic rhinosinusitis

Diagnostic CRS: The individual meets diagnostic criteria for chronic rhinosinusitis.>12 weeks of symptoms plus objective endoscopic and/or CT findings
Failed maximal medical management: The individual has failed maximal medical management before surgery.Nasal irrigation, corticosteroids, and antibiotics

BOD used with FESS

When BOD is used with FESS, apply the following procedural rules.

BOD combined with FESS: When BOD is used as an adjunct to FESS on a different sinus during the same operation, the BOD medical-necessity criteria apply to the sinus treated with BOD. When BOD is used in the same sinus cavity as FESS during the same operation, it is considered integral to the FESS procedure.Different sinus: apply BOD criteria; same sinus: integral to FESS

BOD may be performed as a standalone procedure or as an adjunct to FESS.

FESS for refractory chronic rhinosinusitis

FESS may be appropriate when the patient has CRS and has failed maximal medical management.

FESS candidacy for refractory CRS

Diagnostic CRS: The patient meets diagnostic criteria for chronic rhinosinusitis.Symptoms for at least 12 weeks plus objective evidence of disease or inflammation
Failed medical management: Symptoms remain refractory despite maximal medical management.Nasal irrigation, corticosteroids, and antibiotics as clinically appropriate

Balloon dilation for chronic rhinosinusitis

The evidence is sufficient to determine that balloon sinus ostial dilation improves the net health outcome for selected patients with chronic rhinosinusitis when performed as a standalone procedure.

Standalone balloon dilation for CRS

Sinonasal symptoms: The patient has sinonasal symptoms.
Objective CT disease: CT demonstrates sinonasal disease.
CT is required before balloon dilation.

Balloon dilation for recurrent acute rhinosinusitis

Balloon dilation for recurrent acute rhinosinusitis has limited evidence and requires clinical and CT correlation.

Recurrent acute rhinosinusitis

Recurrent acute sinusitis symptoms: The patient meets the applicable symptom-based definition of recurrent acute sinusitis.
CT findings: CT demonstrates ostial occlusion and mucosal thickening.

Surgical approach for polyps or destructive/infectious disease

When substantial diseased tissue or structural disease is present, treatment should provide full sinus exposure and remove diseased tissue rather than use balloon or manual ostial dilation alone.

Extent of surgery for complex disease: For sinus disease involving polyps, osteitis, bony erosion, or fungal disease, perform or refer for surgery that fully exposes the sinus lumen and removes diseased tissue.Presence of polyps, osteitis, bony erosion, or fungal disease

Balloon-only or manual ostial dilation is not the appropriate extent of treatment for these findings.

Individualized adult sinus surgery candidacy

Adult sinus surgery candidacy should be individualized rather than based solely on arbitrary CT thresholds.

Individualized surgical candidacy

Clinical severity and impact: Assess symptoms, disease severity, and quality-of-life impact.
Prior treatment: Assess prior medical therapy and response.
A fixed regimen or duration should not be required for every adult.
Shared expectations: The patient understands anticipated outcomes and the possibility of chronic disease, continued medical management, relapse, or revision surgery.

Balloon dilation is not appropriate for headache or sleep apnea alone. The patient must otherwise meet the applicable criteria for chronic rhinosinusitis or recurrent acute rhinosinusitis, including the required clinical and objective evidence of sinonasal disease.

When chronic rhinosinusitis involves polyps, osteitis, bony erosion, or fungal disease, balloon or manual ostial dilation alone is not an adequate surgical approach. Treatment should provide full exposure of the sinus cavity and removal of diseased tissue, or the patient should be referred to a surgeon who can provide that extent of surgery.

The extent of sinus surgery should be individualized and should not be determined solely by arbitrary CT thresholds for minimal mucosal thickening, sinus opacification, or outflow obstruction. CT should support surgical planning, but operative extent should also reflect symptoms, disease severity, quality-of-life impact, prior therapy, and anticipated benefit.

For applicable elective sinus procedures, inpatient, on-campus outpatient hospital, and off-campus outpatient hospital sites are not medically necessary when the site-of-service criteria are not met. An ambulatory surgical center should be used when it is an appropriate, safe, and cost-effective setting; hospital-based care requires a qualifying exception, such as lack of an appropriate ASC within 30 miles, a concurrent procedure requiring a hospital outpatient department, or a documented clinical risk that increases the likelihood of complications.

Procedure Codes and Clinical Thresholds

FESS CPT CodesCPTCovered

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.

Balloon Sinus Ostial Dilation CPT CodesCPTCovered

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

Balloon Dilation HCPCS CodeHCPCSCovered

C1726

Catheter, balloon dilatation, nonvascular

FDA product codesmixed

EOB	FDA product code for the FinESS Sinus Treatment; access and treatment of the maxillary ostia/ethmoid infundibulum in adults using a transantral approach
LRC	FDA product code for balloon ostial dilation devices

FDA 510(k) identifiersmixed

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

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Recurrent acute bacterial rhinosinusitis

Recurrent acute bacterial rhinosinusitisFour or more documented episodes within 12 continuous months.

Antibiotic requirementAt least one course of oral antibiotics for 5–7 days within the last 6 months for initial recurrent disease.

Topical treatmentTopical intranasal steroids or daily saline nasal irrigation for at least 4 consecutive weeks.

Chronic rhinosinusitis symptom duration

Minimum durationAt least 12 continuous weeks for policy criteria; chronic rhinosinusitis is also described as symptoms lasting more than 12 weeks.

Qualifying symptomsMucopurulent drainage, nasal congestion or obstruction, facial pain or pressure, or decreased sense of smell.

Objective evidenceSinus disease must also be demonstrated by CT/MRI or nasal endoscopy.

Revision surgery interval

Minimum intervalAt least 12 weeks must have passed since the previous surgery.

Persistent symptomsChronic rhinosinusitis symptoms must have been present for at least 12 continuous weeks.

Persistent diseaseCT/MRI or nasal endoscopy must show persistent objective sinus pathology amenable to surgery.

Antibiotic therapy

Course durationAt least one antibiotic course of 5–7 days must be tried and failed.

Initial recurrent or chronic diseaseFor initial recurrent acute or chronic rhinosinusitis, the course must be within the last 6 months.

Revision surgeryFor revision surgery, the antibiotic course must be completed since the previous surgery.

Topical therapy

Treatment optionsTopical intranasal steroids or daily saline nasal irrigation.

Recurrent acute diseaseUse is required for at least 4 consecutive weeks.

Chronic disease or balloon dilationUse is required for at least 6 consecutive weeks.

Authorization, Documentation, and Denial Risks

Prior Authorization

Pre-Approval Required for Non-Hospital Surgery

Obtain health plan pre-approval before performing sinus surgery that is not performed in a hospital operating room.

Prior Authorization

Procedure and Site-of-Service Review

Submit the elective sinus procedure for medical-necessity review and request separate site-of-service review. The review may address an off-campus or on-campus hospital outpatient department, ambulatory surgical center, or inpatient hospital.

Review both the procedure and the location where it will be performed.

Documentation Required

Document Hospital Site-of-Service Exception

For elective sinus surgery, document why a hospital outpatient or inpatient setting is medically necessary rather than an ambulatory surgical center. The preferred setting is the most appropriate, safe, and cost-effective site.

No qualifying ASC within 30 miles because the necessary equipment is unavailable or the ASC prohibits the procedure based on the individual’s condition or weight.
Individual is age 18 or younger.
A concurrent procedure in the same operative session requires a hospital outpatient department.
A documented condition increases complication risk, such as ASA III or higher, significant cardiovascular, pulmonary, liver, renal, or other qualifying risk.

Unsupported block type: prior_auth

Unsupported block type: step_therapy

Step Therapy

Maximal Medical Therapy Before FESS

Before FESS for uncomplicated chronic rhinosinusitis, document maximal medical management and its failure. The evidence describes maximal therapy as multimodal treatment rather than surgery as an alternative to initial medical care.

Saline nasal irrigation.
Topical and/or systemic corticosteroids when clinically appropriate.
Antibiotic therapy when indicated and documented.
Related management may include other appropriate CRS therapies; record the regimen, duration, and persistent symptoms or disease.

Unsupported block type: documentation

Documentation Required

Recurrent Acute Rhinosinusitis Documentation

For recurrent acute bacterial rhinosinusitis, document at least four episodes within 12 continuous months, treatment failure, and objective evidence of disease before requesting FESS.

Onset and duration of each episode and symptoms.
At least one 5–7-day course of oral antibiotics within the last 6 months, with failure documented.
Topical intranasal steroids or daily saline irrigation for at least 4 consecutive weeks, with failure documented.
CT/MRI results or nasal endoscopy showing pathology amenable to surgical treatment.

Documentation Required

Chronic Rhinosinusitis Documentation

For chronic rhinosinusitis with or without polyposis, document symptoms for at least 12 continuous weeks, failed medical therapy, and objective disease suitable for surgery.

Onset and duration of symptoms.
At least one 5–7-day antibiotic course within the last 6 months.
Topical intranasal steroids or daily saline irrigation for at least 6 consecutive weeks.
CT/MRI or nasal endoscopy showing sinus pathology amenable to surgical treatment.

Documentation Required

Revision FESS Documentation

For revision FESS, document the interval from the prior surgery, persistent CRS symptoms, failed treatment, and persistent objective disease.

At least 12 weeks since the previous surgery.
CRS symptoms present for at least 12 continuous weeks.
At least one 5–7-day antibiotic course since the previous surgery, with failure documented.
CT/MRI or nasal endoscopy showing persistent pathology amenable to surgical treatment.

Documentation Required

Balloon Dilation Documentation

For balloon sinus ostial dilation, document chronic sinonasal symptoms, failed medical therapy, and objective disease on CT/MRI or endoscopy.

Symptoms present for at least 12 continuous weeks.
At least one 5–7-day antibiotic course.
Topical intranasal steroids or daily saline irrigation for at least 6 consecutive weeks.
Imaging or endoscopy showing pathology amenable to treatment.

Unsupported block type: documentation

Unsupported block type: denial_risk

Clinical Background

Rhinosinusitis is inflammation of the nasal cavities and paranasal sinuses and may be acute or chronic. Acute rhinosinusitis generally lasts less than 4 weeks, whereas chronic rhinosinusitis involves symptoms lasting more than 12 weeks, with or without acute exacerbations, and may occur with or without nasal polyps. Chronic disease is supported by objective evidence of sinonasal inflammation or disease on nasal endoscopy or sinus CT/MRI. Surgical treatment is considered after appropriate medical therapy has failed and objective disease amenable to surgery is documented.

Clinical and Functional Definitions

Recurrent acute rhinosinusitis

Episode thresholdFour or more acute bacterial rhinosinusitis episodes per year.

Between episodesSymptoms do not persist between episodes.

Clinical patternEpisodes are acute and bacterial in nature.

Rhinosinusitis

DefinitionSymptomatic inflammation of the paranasal sinuses and nasal cavities.

Preferred terminologyRhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa.

ClassificationRhinosinusitis may be classified by symptom duration as acute or chronic.

Chronic rhinosinusitis

DurationSymptoms last more than 12 weeks, with or without acute exacerbations.

SymptomsAt least two symptoms, including nasal blockage, obstruction, congestion, or nasal discharge, with or without facial pain or pressure and reduced or lost smell.

Objective findingsEndoscopic mucopurulence, edema, or polyps and/or CT evidence of mucosal thickening or air-fluid levels.

American Society of Anesthesiologists (ASA) Score

ASA 1A normal healthy patient.

ASA 2A patient with mild systemic disease.

ASA 3A patient with severe systemic disease.

ASA 4A patient with severe systemic disease that is a constant threat to life.

New York Heart Association (NYHA) Classification

Class INo symptoms and no limitation in ordinary physical activity.

Class IIMild symptoms and slight limitation during ordinary activity.

Class IIIMarked limitation in activity due to symptoms; comfortable only at rest.

Class IVSevere limitations with symptoms even while at rest; mostly bedbound patients.

Recurrent acute rhinosinusitis

Episode thresholdFour or more acute episodes of acute bacterial rhinosinusitis per year.

Persistent symptomsThere are no persistent symptoms between episodes.

Disease typeEach episode is acute bacterial rhinosinusitis.

Rhinosinusitis

DefinitionSymptomatic inflammation of the paranasal sinuses and nasal cavities.

Acute durationAcute rhinosinusitis lasts less than 4 weeks.

Chronic durationChronic rhinosinusitis lasts more than 12 weeks.

Chronic rhinosinusitis

DurationSymptoms last more than 12 weeks, with or without acute exacerbations.

Qualifying symptom profileAt least two symptoms, including nasal blockage, congestion, or discharge, with or without facial pain or pressure and reduced or lost smell.

Objective evidenceEndoscopy may show mucopurulence, edema, or polyps; CT may show mucosal thickening or air-fluid levels.

Silent sinus syndrome

ConditionA rare condition involving spontaneous, generally asymptomatic collapse of an air sinus.

MechanismThe collapse is associated with negative sinus pressure.

Typical site and confirmationIt generally affects the maxillary sinus and is confirmed by computed tomography.

Complicated rhinosinusitis

DefinitionRhinosinusitis with clinical extension of inflammation outside the paranasal sinuses and nasal cavity at diagnosis.

ExtentInflammation extends beyond the paranasal sinuses.

TimingThe extension is present at the time of diagnosis.

Maximal medical therapy

PurposeA presurgical medical-treatment standard used before endoscopic sinus surgery.

Common componentsReported components vary; studies most often used topical steroids and oral antibiotics.

Reported durationsAmong studies specifying criteria, mean durations were 8.4 weeks for topical steroids and 23 days for oral antibiotics.

Balloon ostial dilation

ProcedureA balloon is placed in the sinus ostium and inflated to stretch and dilate the opening.

TechniqueA guidewire may be placed in the sinus ostium, with the balloon advanced over the guidewire before inflation.

UseThe procedure may be performed as a standalone procedure or as an adjunct to FESS.

Chronic rhinosinusitis (CRS)

DurationChronic rhinosinusitis lasting 12 weeks or longer.

SymptomsAt least two sinonasal symptoms, such as mucopurulent drainage, nasal obstruction, facial pain or pressure, or decreased sense of smell.

Objective findingAt least one objective finding of sinonasal inflammation or disease on nasal endoscopy or CT.

CRSwNP

AbbreviationCRSwNP.

DefinitionChronic rhinosinusitis with nasal polyps.

Clinical findingNasal polyps are visible on rhinoscopy or nasal endoscopy.

CRSsNP

AbbreviationCRSsNP.

DefinitionChronic rhinosinusitis without nasal polyps.

Subtype distinctionThe disease is categorized as CRSsNP when nasal polyps are absent.

CRS subtype

With nasal polypsCRSwNP means chronic rhinosinusitis with nasal polyps.

Without nasal polypsCRSsNP means chronic rhinosinusitis without nasal polyps.

Classification ruleCRS is categorized as CRSwNP or CRSsNP according to whether nasal polyps are present.