Currentpriority healthPolicy N/A

Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation

Defines medical necessity, documentation, coding, and reimbursement guidance for balloon sinus ostial dilation (BSOD) for chronic sinusitis and eustachian tube balloon dilation (ETBD) for eustachian tube dysfunction for Priority Health members.

Policy Summary

Payerpriority health

PolicyBalloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument persistent symptoms and prior therapy: for chronic sinusitis record >3 months of symptoms, failure of >3 months medical therapy including at least two antibiotics plus topical agents before BSOD is considered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥3 moDuration required for chronic rhinosinusitis documentation

≥6 moSymptom duration threshold for ETD

31295-31298Key procedure codes

S1091Non-covered device

Coverage and Medical Necessity Criteria

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BSOD (Chronic Sinusitis) Medical Necessity Criteria

Covered when ALL of the following are met for BSOD (chronic sinusitis):

BSOD criteria: 1) Documentation of persistent rhinosinusitis for greater than three months; 2) Documented failure of greater than three months of medical therapy demonstrated by persistent upper respiratory symptoms despite therapy — therapy must consist of a minimum of two different antibiotics with a trial of steroid spray, antihistamine spray, and/or decongestant; 3) Radiological evidence of at least ONE of the following: air-fluid levels; mucosal thickening greater than 2 mm; opacification; nasal polyposis.> 3 months

Radiologic findings must be documented in the medical record (imaging report or image availability).

ETBD (Eustachian Tube Dilation) Medical Necessity Criteria

Covered when ALL of the following are met for ETBD (Eustachian Tube Dysfunction):

ETBD criteria: 1) Patient is an adult (≥ 18 years); 2) Symptoms present for at least 6 months — examples include aural fullness, aural pressure/otalgia, hearing loss, or autophony, or history of chronic ear disease or intolerance to barometric changes greater than six months; 3) Tympanic membrane abnormality on exam; 4) Complete nasal endoscopy assessing the eustachian tube lumen confirming transnasal access to the nasopharynx and elimination of extrinsic causes of ETD; 5) Failure, intolerance, or contraindication to appropriate management of co-occurring conditions; 6) Tympanometry of an intact tympanic membrane showing a Type A, B, or C tympanogram; 7) History of prior tympanostomy tube placement demonstrating relief from symptoms while tubes were present; 8) If BSOD and ETBD are performed concurrently, documentation must meet both sets of criteria.>= 6 months

Complete and thorough documentation to substantiate the procedure performed is the responsibility of the provider; include relevant exam, endoscopy, tympanometry, prior treatment history, and imaging when applicable.

Balloon sinus ostial dilation (BSOD) performed contemporaneously with functional endoscopic sinus surgery (FESS) is considered an integral part of the primary FESS procedure and is not separately reimbursable. When BSOD is done as part of FESS, do not bill for BSOD as an additional separately payable service. Additionally, diagnostic endoscopy codes 31231, 31233, and 31235 should not be reported on the same side on the same date of service as the primary procedure.

The Propel sinus stent identified by HCPCS code S1091 (Stent, noncoronary, temporary, with delivery system — Propel) is explicitly listed as a non‑covered item and is not covered for reimbursement.

Consolidated coverage guidance: BSOD performed during FESS is integral to the FESS procedure and will not be reimbursed separately. Providers should also note that the Propel stent (HCPCS S1091) is not covered and must not be billed as a payable supply.

Coding and Billing

Covered CPT/HCPCS codes referencedmixedCovered

31295	Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium, transnasal or via canine fossa.
31296	Nasal/sinus endocopy, surgical; with dilation of frontal sinus ostium.
31297	Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium.
31298	Nasal/sinus endoscopy, surgical; eith dilation of frontal and sphenoid sinus ostia.
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 (Not covered with Propel system).
J4702	Mometasone furoate sinus implant, 10mcg.

Non covered codesHCPCSNot Covered

S1091

Stent, noncoronary, temporary, with delivery system (Propel)

Symptom duration thresholds — chronic sinusitis and ETD

Chronic sinusitis symptom durationDocumentation of persistent rhinosinusitis for greater than three months is required.

ETD symptom durationSymptoms present for at least 6 months (e.g., aural fullness, aural pressure/otalgia, hearing loss, autophony) or history of chronic ear disease/intolerance to barometric changes >6 months.

Medical therapy duration for chronic sinusitisDocumented failure of greater than three months of medical therapy is required before BSOD (includes minimum of two different antibiotics plus trial of steroid spray, antihistamine spray, and/or decongestant).

Provider Requirements, Documentation, and Billing Guidance

Prior Authorization

Medicare PSOD Requirement

For Medicare indications that do not meet criteria of an NCD, local LCD, or a specific medical policy, a Pre-Service Organization Determination (PSOD) must be completed prior to providing the service.

Applies when no applicable NCD/LCD or specific medical policy exists
Provider must submit PSOD per Medicare requirements

Documentation Required

Chronic Sinusitis Documentation

For treatment of chronic rhinosinusitis, the medical record must document all of the following: persistent rhinosinusitis for greater than three months; failure of greater than three months of medical therapy; and supporting radiologic findings.

Documentation of persistent rhinosinusitis > 3 months
Documented failure of > 3 months of medical therapy consisting of at minimum: two different antibiotics plus a trial of steroid nasal spray, antihistamine spray, and/or a decongestant
Radiological evidence of at least one of: air-fluid levels; mucosal thickening > 2 mm; sinus opacification; or nasal polyposis

Denial Risk

Denial Risk for Insufficient Documentation or Incorrect Coding

Failure to document required clinical history, prior medical therapy, radiologic findings, or to apply correct billing modifiers and codes may result in claim denial. Providers are responsible for maintaining complete records that substantiate the services billed.

Failure to document services rendered will result in denial
Ensure use of industry-standard CPT/HCPCS/revenue codes and correct modifiers
Authorization does not guarantee payment if documentation or coding requirements are not met

Background and Rationale

Balloon sinus ostial dilation (BSOD) uses an inflatable balloon to dilate sinus ostia to improve drainage and is an adjunct technique in managing chronic rhinosinusitis. Eustachian tube balloon dilation (ETBD) places and inflates a balloon within the eustachian tube to remodel the lumen and address eustachian tube dysfunction. When BSOD is performed as part of functional endoscopic sinus surgery (FESS), it is considered integral to that primary procedure and is not separately reimbursable. Separately, temporary noncoronary stents delivered via systems such as the Propel device (HCPCS S1091) are identified in this policy as not covered.

Definitions

Balloon sinus ostial dilation (BSOD) — definition and technique

DefinitionBalloon sinus ostial dilation (BSOD) is a technique in which a small balloon-like device is placed within the sinus passage or sinus ostia and inflated to move aside tissue and bone to create a larger airway passage and allow drainage of nasal secretions.

PurposeEnlarge sinus ostia to improve drainage in chronic sinusitis.

Procedure characteristicBalloon is inflated within the ostia to reposition tissue and bone rather than remove tissue.

Eustachian tube balloon dilation (ETBD) — definition and technique

DefinitionEustachian tube balloon dilation (ETBD) is a technique in which a small balloon-like device is placed into the eustachian tube and inflated to remodel the cartilage of the passageway.

Indication contextUsed to address eustachian tube dysfunction (ETD) when documentation criteria are met (adults ≥18, symptoms ≥6 months, tympanic membrane abnormality, etc.).

Concurrent procedure noteWhen performed concurrently with BSOD, both ETBD and BSOD documentation criteria must be satisfied.

Chronic sinusitis — definition

DefinitionChronic sinusitis is prolonged or recurrent infection and inflammation of the nasal sinuses.

Documentation requirementRequires documentation of persistent rhinosinusitis for greater than three months.

Supporting radiologyRadiologic evidence must show at least one: air-fluid levels; mucosal thickening >2 mm; opacification; or nasal polyposis.

Eustachian tube dysfunction (ETD) — definition

DefinitionEustachian tube dysfunction (ETD) is a physiological disorder of the eustachian tube resulting in inability to appropriately equalize pressure between the middle ear and environment.

Clinical featuresTypical symptoms include aural fullness, aural pressure/otalgia, hearing loss, and autophony lasting ≥6 months.

Diagnostic findingsMay include tympanic membrane abnormality on exam and tympanometry showing Type A, B, or C; complete nasal endoscopy should assess ET lumen and exclude extrinsic causes.