Modifiedpriority healthPolicy N/A

BALLOON SINUS OSTIAL DILATION FOR CHRONIC SINUSITIS AND EUSTACHIAN TUBE DILATION

Defines medical necessity, exclusions, limitations, coding, and regulatory background for balloon sinus ostial dilation (Balloon Sinuplasty) for chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS), and for Eustachian tube balloon dilation (ETBD) in adults and select pediatrics.

Policy Summary

Payerpriority health

PolicyBALLOON SINUS OSTIAL DILATION FOR CHRONIC SINUSITIS AND EUSTACHIAN TUBE DILATION

Policy CodePolicy N/A

Change TypeMODIFIED — criteria additions, removals, and thresholds updated

Effective DateJun 1, 2026

Next Review Date

Key ActionPrior authorization may be required; providers must submit requests demonstrating medical necessity per policy and follow Priority Health Provider Manual for PA requirements.

SourceLink

POLICY UPDATE CHANGES

Removed tobacco use as an exclusion for Eustachian tube balloon dilation (ETBD).

Added medical necessity criteria for recurrent acute rhinosinusitis.

Added medically necessity criteria for chronic obstructive Eustachian tube dysfunction in pediatrics (ages 8-17).

Removed age criteria of 18 and up for eustachian tube dysfunction and added pediatric criteria.

Removed the strict ≥3-month predefined medical therapy regimen requirement for chronic rhinosinusitis, allowing individualized, patient-centered medical management prior to surgery.

Symptom duration threshold for ETBD changed from 6 months to 3 months.

Moved billing criteria for balloon sinus ostial dilation to the 'limitations' section.

Made editorial and grammatical updates to improve clarity.

2Primary covered conditions (CRS, RARS)

2ETBD populations (Adults, Pediatrics 8-17)

Lifetime procedural limit for ETBD (adults)

1Experimental device category

Coverage Summary

Coverage includes balloon sinus ostial dilation (Balloon Sinuplasty) for adults with chronic rhinosinusitis (CRS) and for patients with recurrent acute rhinosinusitis (RARS), when diagnostic and medical-therapy criteria are met. It also includes Eustachian tube balloon dilation (ETBD/BDET) for adults and for select pediatric members aged 8–17 years with specified indications.

Key thresholds / facts

CRS chronicity> 3 months

CRS diagnostic symptom requirementTwo or more sinonasal symptoms, at least one must be nasal obstruction/congestion or nasal drainage

RARS episode count>= 4 episodes in 12 continuous months

Radiographic mucosal thickening threshold> 2 mm

ETD symptom duration for ETBD>= 3 months

ETBD lifetime procedural limit (adults)Once per lifetime

Medical-Necessity Criteria

Coding

ICD-10 supporting diagnosesICD-10

J32.0	Chronic maxillary sinusitis
J32.1	Chronic frontal sinusitis
J32.2	Chronic ethmoidal sinusitis
J32.3	Chronic sphenoidal sinusitis
J32.4	Chronic pansinusitis
J32.8	Other chronic sinusitis
J32.9	Chronic sinusitis, unspecified

CPT / HCPCS codes for proceduresCPT|HCPCS|mixedCovered

31295	Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or via canine fossa
31296	Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation)
31297	Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g., balloon dilation)
31298	Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)
69705	Nasopharyngoscopy, surgical, with dilation of eustachian tube; unilateral
69706	Nasopharyngoscopy, surgical, with dilation of eustachian tube; bilateral
C2625	Stent, noncoronary, temporary, with delivery system
J7402	Mometasone furoate sinus implant (Sinuva), 10 mcg

Not Medically Necessary / Experimental codesHCPCS|mixedNot Covered

S1091	Stent, noncoronary, temporary, with delivery system (Propel) - considered experimental/investigational
C2625	Stent, noncoronary, temporary, with delivery system (sinus ostial maintenance devices) - considered experimental/investigational

Provider Actions & Billing Rules

Prior Authorization

Prior authorization may be required

Prior authorization for procedures/devices may be required; providers must submit requests demonstrating medical necessity per policy and follow Priority Health Provider Manual for PA requirements.

Documentation Required

Document symptoms, prior medical therapy, and objective findings

Providers must document symptom duration, prior appropriate medical therapy and objective radiological or endoscopic evidence to support medical necessity.

Air fluid levels
Mucosal thickening > 2 mm
Partial or complete opacification
Obstructive inflammatory tissue consistent with nasal polyposis

Background and Evidence

CRS is defined as persistent sinonasal symptoms with objective mucosal disease lasting at least 12 weeks, and RARS as discrete acute bacterial sinusitis episodes typically >= 4 episodes in 12 months with symptom resolution between episodes. Society guidelines (AAO-HNS, ARS) acknowledge the heterogeneity of disease and emphasize individualized, patient-centered decision-making rather than fixed medication thresholds. Balloon sinus ostial dilation and ETBD are recognized by these societies as minimally invasive therapeutic options for carefully selected patients with objective disease who have failed appropriate medical management.

Definitions

Evidence

AAO-HNS guidelineSupports individualized medical management and use of sinus ostial dilation when diagnostic criteria met (2025/2021 references).

RARS definition>=4 acute episodes in 12 months per ARS (2023).

Objective radiographic thresholdsMucosal thickening > 2 mm; air-fluid levels; partial/complete opacification; obstructive inflammatory tissue.

Revision History

05/13/2026removedLatest

Removed tobacco use as an exclusion for Eustachian tube balloon dilation (ETBD).

05/13/2026addedLatest

Added medical necessity criteria for recurrent acute rhinosinusitis (RARS): documentation of four or more episodes in 12 months, failure of appropriate medical therapy for each episode, sinonasal symptoms correlating with CT findings, and objective radiologic evidence (air-fluid level, mucosal thickening > 2 mm, opacification, or obstructive inflammatory tissue).

05/13/2026

Policy Summary

Payerpriority health

PolicyBALLOON SINUS OSTIAL DILATION FOR CHRONIC SINUSITIS AND EUSTACHIAN TUBE DILATION

Policy CodePolicy N/A

Change TypeMODIFIED — criteria additions, removals, and thresholds updated

Effective DateJun 1, 2026

Next Review Date

Key ActionPrior authorization may be required; providers must submit requests demonstrating medical necessity per policy and follow Priority Health Provider Manual for PA requirements.

SourceLink

On This Page

Billing Rule

Adjunct to FESS not separately reimbursable

Balloon sinus ostial dilation when performed as an adjunct to functional endoscopic sinus surgery (FESS) is integral to the primary FESS procedure and is not separately reimbursable.

31295
31296
31297
31298

Denial Risk

Experimental device exclusion

Claims for sinus ostial maintenance devices (e.g., Propel, Relieva Stratus, Sinu-Foam) or other indicated investigational uses are considered experimental/investigational and are not covered absent case-by-case approval.

S1091
C2625

Documentation Required

ETBD tympanometry and prior tube history

For ETBD, providers must document tympanometry results, prior tympanostomy tube history and relief when applicable, and exclude structural/extrinsic causes via nasal endoscopy.

Tympanometry (Type A with documented prior tube symptom relief, OR Type B or Type C)
Documentation of prior tympanostomy tube placement and symptom relief while tubes were patent

ETBD pediatric indication

Considered medically necessary for select pediatric patients (ages 8–17) with obstructive ETD and chronic otitis media refractory to standard surgical interventions.

Supporting ICD-10 codesJ32.0–J32.9 (chronic sinusitis codes).

Procedure codes31295–31298 (sinus ostial dilation); 69705–69706 (ET dilation); C2625, J7402 (devices/implants).

Added medical necessity criteria for chronic obstructive Eustachian tube dysfunction in pediatrics (ages 8-17): obstructive ETD with chronic otitis media refractory to standard surgical interventions (e.g., tympanostomy tube placement and adenoidectomy).

05/13/2026revisedLatest

Removed the age criterion requiring adults 18 and older only for ETBD and added a pediatric section with specific criteria for ages 8-17.

05/13/2026revisedLatest

Removed the strict ≥3-month predefined medical therapy regimen requirement for chronic rhinosinusitis, allowing individualized, patient-centered medical management prior to surgery as supported by guideline recommendations.

05/13/2026revisedLatest

Symptom duration threshold for ETBD changed from 6 months to 3 months (ETD symptoms continuously ≥ 3 months required).

05/13/2026revisedLatest

Moved billing criteria for balloon sinus ostial dilation to the 'limitations' section.

05/13/2026clarifiedLatest

Made editorial and grammatical updates to improve clarity.