Currentsierra health and lifePolicy 2026T0571T

Sinus Surgeries and Interventions (Balloon sinus ostial dilation and FESS)

Clinical coverage policy for balloon sinus ostial dilation (BSD), functional endoscopic sinus surgery (FESS), and related sinus interventions for UnitedHealthcare Commercial and Individual Exchange members; defines medical necessity, limitations, and required supporting documentation.

Policy Summary

Payersierra health and life

PolicySinus Surgeries and Interventions (Balloon sinus ostial dilation and FESS)

Policy CodePolicy 2026T0571T

Change TypeMinor / no material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior medical therapy failure and a recent sinus CT (within 12 months) demonstrating objective disease before requesting authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 weeksCRS minimum duration

4+/yrRARS threshold

CT ≤12moRecent CT definition

97.5%Technical success (balloon)

InsufficientSelf‑expanding devices

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Coverage Criteria for BSD and FESS

Covered indications

Balloon sinus ostial dilation and/or Functional Endoscopic Sinus Surgery (FESS) are proven and medically necessary when ONE OR MORE of the following are present:

Chronic Rhinosinusitis (CRS): CRS lasting longer than 12 weeks AND persistence of symptoms despite recent medical management including intranasal corticosteroids (and/or oral corticosteroids when appropriate), antibiotic therapy if bacterial infection is suspected, and nasal lavage/irrigation when appropriate; AND confirmation of CRS on a Recent CT Scan for each sinus to be treated obtained after completion of medical management with documentation of which sinus has disease and extent of disease (percent opacification or modified Lund‑Mackay score); CT findings may include bony remodeling, bony thickening, opacified sinus, or ostial obstruction and mucosal thickening; AND sinonasal symptoms (pain, pressure, drainage) on the same side as CT findings; AND for balloon dilation only, dilation is limited to frontal, maxillary, or sphenoid sinuses.symptoms >12 weeks; recent CT within 12 months

Supports both BSD and FESS when met

Recurrent Acute Rhinosinusitis (RARS): Four or more episodes per year with distinct symptom‑free intervals AND sinonasal symptoms on the same side as CT findings AND Recent CT evidence: for balloon sinus ostial dilation—ostial obstruction and mucosal thickening in the sinus to be dilated; for FESS—maxillary, frontal, or sphenoid sinuses require ostial obstruction and mucosal thickening in the sinus to be treated (ethmoid requires mucosal thickening).>=4 episodes/year

Surgery considered when criteria met and medical therapy failed

Specific CT‑confirmed conditions for FESS: FESS is medically necessary when CT confirms complications of sinusitis such as abscess, symptomatic concha bullosa, symptomatic mucocele, polyposis with obstructive symptoms, or sinonasal tumor.

These are standalone indications for FESS

Not medically necessary / experimental

Not covered / unproven

BSD not medically necessary: Balloon sinus ostial dilation is unproven and not medically necessary for treating sinonasal polyps or tumors and for cases of CRS or RARS that do not meet the policy criteria.

Insufficient evidence of efficacy

FESS not medically necessary: Functional Endoscopic Sinus Surgery (FESS) is unproven and not medically necessary for cases of CRS or RARS that do not meet the criteria above due to insufficient evidence of efficacy.

Insufficient evidence of efficacy

Self‑expanding absorptive dilation not medically necessary: Self‑expanding absorptive sinus ostial dilation devices are unproven and not medically necessary for evaluating or treating sinusitis and other conditions due to insufficient evidence of efficacy.

Device (e.g., investigational absorptive devices) under study

Appropriate indications

Covered when ALL of the following are met (per consensus and guideline statements):

Patient selection: Clinical diagnosis of CRS or RARS based on sinusitis symptoms.

AAO‑HNS/ARS consensus supports BSD for selected patients

Objective documentation: Nasal endoscopy demonstrating sinonasal abnormality or CT showing mucosal thickening and/or ostial occlusion (CT generally obtained after medical therapy).

CT scanning is a requirement before balloon dilation per AAO‑HNS consensus

Failure of medical therapy: Failure of appropriate medical management (e.g., topical intranasal corticosteroids and saline irrigation; antibiotics where indicated) prior to surgical consideration.

Guidelines recommend medical therapy before surgical management

Anatomic target:

Inappropriate indications

Not supported / inappropriate indications identified by consensus:

Lack of objective disease: Patients without sinonasal symptoms and without positive CT findings.

Consensus: balloon dilation not appropriate

Headache or sleep apnea without CRS/RARS: Management of headache or sleep apnea in patients who do not meet criteria for CRS or RARS.

Consensus: not appropriate indication

Coverage for BSD and FESS

Covered when ALL of the following are met

Patient selection: Clinical diagnosis of CRS or RARS based on sinusitis symptoms plus objective confirmation by nasal endoscopy or CT demonstrating sinonasal abnormality or mucosal thickening.

(ARS 2023; ACR 2021)

Failure of medical therapy: Failure of appropriate medical therapy (e.g., intranasal corticosteroids, saline irrigation, and other adjuncts; antibiotics as indicated) prior to consideration of surgical intervention.

(ARS 2023; AAAAI/ACAAI/JCAAI guidance)

Procedure choice: Balloon ostial dilation may be used alone for dilation of obstructed ostia in selected patients with mild or localized disease or in conjunction with other instruments; FESS of varying extent is appropriate for more extensive disease based on surgeon judgment and disease severity.

(ARS 2023; EUFOREA 2020; NICE 2016; Tran et al. 2024)

Criteria informing extent of surgery

Considerations influencing choice of ESS extent

Extent vs outcomes: Greater extent of ESS (full‑house, radical) generally yields greater improvements in patient‑reported outcomes and lower recurrence/revision rates compared to limited ESS, while perioperative complication rates are similar across extents.

(Tran et al. 2024)

RCT evidence: Randomized trial data (Lourijsen et al. 2022) show ESS plus medical therapy provided superior SNOT‑22 outcomes at 12 months versus medical therapy alone, though the minimal clinically important difference was not met in that study.

(Lourijsen 2022)

Indications for ESS or balloon dilation

Covered when ALL of the following are met:

Primary criteria: 1) Persistent CRS symptoms despite appropriate medical therapy (topical intranasal corticosteroids and saline irrigation, +/- antibiotics); 2) Objective evidence of disease on nasal endoscopy and/or CT scan; 3) Documentation of symptom burden (e.g., SNOT‑22 >=20 or equivalent) or other guideline‑consistent indicators such as recurrent acute rhinosinusitis, complications, or sinonasal polyposis affecting airway or asthma control.See SNOT‑22 and Lund‑Mackay thresholds

Based on AAO‑HNS, ICAR‑RS, EUFOREA, and allergy society recommendations.

Pediatric ESS considerations

Pediatric considerations — covered when ALL of the following are met:

Pediatric criteria: 1) Failure of medical therapy for pediatric CRS or RARS; 2) Consideration of adenoidectomy as a first‑line surgical procedure and strong consideration to perform adenoidectomy at least three months prior to more extensive sinus surgery when applicable; 3) Objective evidence of disease on nasal endoscopy or CT when surgery is planned.

Per AAO‑HNS pediatric consensus and clinical indicators.

Balloon sinus ostial dilation is explicitly excluded for treatment of sinonasal polyps or tumors. In addition, placement of self‑expanding absorptive sinus ostial dilation devices is not supported for any sinusitis indications due to insufficient evidence and is considered not medically necessary/investigational (limited studies, small sample sizes, and lack of comparison groups).

Balloon ostial dilation is not appropriate for patients who do not have both sinonasal symptoms and positive CT findings demonstrating sinonasal disease. Consensus guidance also indicates balloon dilation is not appropriate for management of isolated headache (or sleep apnea) in patients who do not otherwise meet diagnostic criteria for CRS or RARS.

NICE guidance on the XprESS multi‑sinus dilation system recommends XprESS may be considered for patients with uncomplicated CRS but specifies it should not be used in patients with severe nasal polyposis. More broadly, guideline statements view balloon ostial dilation as a treatment option principally for uncomplicated or localized disease rather than extensive polyposis or advanced sinonasal pathology.

Available evidence for self‑expanding absorptive sinus ostial dilation devices is insufficient to support their routine use. Published reports are limited by small sample sizes and absence of comparative control groups, and therefore do not establish effectiveness or durability compared with standard approaches.

This Medical Policy is provided to assist interpretation of UnitedHealthcare standard benefit plans and is for informational purposes only; it does not constitute medical advice. Coverage decisions must reference the member‑specific benefit plan document, which governs if its terms differ from this policy. Verify any applicable federal or state mandates and the member plan before authorizing services.

When the policy criteria are not met, both Functional Endoscopic Sinus Surgery (FESS) and Balloon Sinus Dilation (BSD) are considered not medically necessary. Separately, use of self‑expanding absorptive dilation devices for sinusitis is considered not medically necessary/investigational because existing evidence does not support their efficacy for sinus disease.

Systematic reviews and professional society summaries do not demonstrate clear superiority of balloon dilation over FESS. The literature is limited in some areas, and conclusions about long‑term disease resolution with minimally invasive approaches (e.g., balloon dilation alone) remain unproven for certain patient subgroups.

Using balloon dilation as a substitute for comprehensive FESS in patients with extensive CRS or severe disease is unproven and remains a subject of debate. Professional guidance emphasizes that balloon techniques may be appropriate for selected, limited disease, while more extensive disease often requires a more comprehensive endoscopic surgical approach.

Given the limited and low‑quality evidence available, placement of self‑expanding absorptive sinus ostial dilation devices is considered not medically necessary or investigational. The studies to date lack robust comparative data and are insufficient to support routine clinical adoption for sinusitis management.

Coding and Objective Criteria

Applicable CPT codes (group 1)CPT

31240	Nasal/sinus endoscopy, surgical; with concha bullosa resection.
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)

Applicable CPT codes (group 2)CPT

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, including removal of tissue from frontal sinus, when performed.
31287	Nasal/sinus endoscopy, surgical, with sphenoidotomy;
31288	Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus.
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.

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1/2

Applicable CPT codes (group 3)CPT

31298	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia.
31299	Unlisted procedure, accessory sinuses

Device product code / regulatorymixed

LRC	FDA product code for ENT manual surgical instruments including balloon catheter dilation devices

inv-22: Recent CT Scan — performed within 12 months of planned procedure.

DefinitionCT scan performed within 12 months of the planned procedure is considered 'recent'

PurposeUsed to document disease extent and specific sinus involvement prior to surgical intervention

Documentation requirementCT should include percent opacification or Modified Lund-Mackay scoring when available

inv-23: Lund-Mackay CT score threshold — ≥ 13.1 may predict better long-term prognosis after FESS.

Threshold>= 13.1 Lund-Mackay (pre-op) may predict better long-term prognosis after FESS

Source study

Provider Requirements, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for sinus surgical procedures (including endoscopic sinus surgery and balloon sinus ostial dilation) described by the applicable CPT/HCPCS codes. Prior authorization requests must document that the member has failed appropriate medical therapy (see Medical Therapy Before Surgery) and include objective imaging and/or endoscopic documentation of disease.

Prior authorization must confirm documented trials of maximal medical therapy (tops: intranasal corticosteroids, nasal saline irrigation; systemic or topical antibiotics only when bacterial infection is suspected; oral corticosteroids when clinically appropriate).
Include dates, dosages, duration, and response to each medical therapy trial in the submitted medical records.
Attach a Recent CT scan (performed within 12 months of planned procedure) documenting the extent of disease for each sinus to be treated (percent opacification or Modified Lund-Mackay scores) and/or nasal endoscopy findings.

Documentation Required

Supportive Imaging and Objective Diagnostic Documentation

Definitions and Background

Chronic rhinosinusitis (CRS) is inflammation of the paranasal sinuses lasting more than 12 weeks and is diagnosed based on persistent sinonasal symptoms plus objective evidence of inflammation (nasal endoscopy or CT). Typical presenting features include nasal obstruction or congestion, mucopurulent drainage, facial pain or pressure, and reduced or lost sense of smell; objective sinonasal inflammation on endoscopy or CT is required to support the diagnosis before surgical intervention is considered.

inv-49: Acute Rhinosinusitis (ARS) definition — sudden onset, up to 4 weeks.

DefinitionAcute Rhinosinusitis (ARS) is inflammation with sudden onset purulent nasal drainage plus nasal obstruction and/or facial pain/pressure/fullness lasting up to 4 weeks.

Key symptomsPurulent drainage and nasal obstruction or facial pain/pressure

DurationUp to 4 weeks per Rosenfeld et al., 2015

inv-50: Chronic Rhinosinusitis (CRS) definition — >12 weeks with two or more symptoms.

Policy Summary

Payersierra health and life

PolicySinus Surgeries and Interventions (Balloon sinus ostial dilation and FESS)

Policy CodePolicy 2026T0571T

Change TypeMinor / no material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain and document prior medical therapy failure and a recent sinus CT (within 12 months) demonstrating objective disease before requesting authorization.

SourceLink

On This Page

Obstructed frontal, maxillary, or sphenoid ostium identified as the target for dilation (for BSD) or sinus target(s) identified for FESS.

Procedure may be standalone or adjunct to FESS

Prospective single-institution study (Singh et al. 2020) reported mean pre-op Lund-Mackay 13.16 ±4.5 and better long-term outcomes for patients with scores >=13.1

UseCan be used as a diagnostic predictor for selecting patients likely to benefit from FESS

inv-24: Mean SNOT-22 change considered in meta-analysis — Mean change 26.02 reported across studies.

Mean changeMean SNOT-22 change after ESS = 26.02 across included studies

Study detailsFu et al. (2023) meta-analysis of 15 prospective cohort studies (average follow-up 25.5 months) reported SNOT-22 changes ranging 5.1 to 55.4

InterpretationNine studies had mean change >=26.02; improvement influenced by baseline SNOT-22, age, and follow-up duration

inv-25: SNOT-22 — threshold referenced in guideline/consensus statements.

Threshold referencedSNOT-22 >= 20 cited as a preoperative threshold in guideline/consensus statements (ICAR-RS and EUFOREA)

Guideline supportICAR-RS 2021 lists pre-op SNOT-22 >=20 as one criterion for ESS candidacy

ContextEUFOREA links SNOT-22 >=20 to post-treatment decision-making alongside Lund-Mackay and a trial of topical therapy

inv-26: Lund-Mackay CT score — referenced threshold (>=1) per EUFOREA for offering ESS.

Threshold>= 1 Lund-Mackay score referenced by EUFOREA as a criterion for offering ESS in uncomplicated CRSsNP

ContextEUFOREA 2020 states a CT showing disease and Lund-Mackay >=1 plus a minimum trial of topical intranasal corticosteroid and adjunct antibiotics can support offering ESS

Intended useUsed to identify adults with uncomplicated CRSsNP who may be appropriate for surgery after medical therapy

Supportive imaging and prior medical therapy are prerequisites for surgical consideration. CT imaging of the paranasal sinuses is essential and should generally be obtained after completion of medical management. Imaging must document disease in the sinus(es) to be treated (e.g., ostial obstruction, mucosal thickening, opacification, or bony change). Nasal endoscopy documenting sinonasal inflammation or purulence can be used as objective confirmation.

Recent CT scan = within 12 months of planned procedure.
CT documentation should identify which sinus(es) are affected and quantify extent of disease (percent opacification or Modified Lund-Mackay scoring).
Nasal endoscopy findings (inflammation, purulence, polyps) may substitute for or complement CT when available.

Documentation Required

Medical Therapy Before Surgery (Prerequisites)

Medical therapy should be tried and documented prior to surgical management. Appropriate medical therapy includes intranasal corticosteroids and adjunctive measures (saline irrigation). Antibiotics have a limited role and should be used when bacterial infection is suspected; oral corticosteroids may be used when clinically indicated. Trials should be adequate in dose and duration and documented in the medical record.

Documented trials should include duration, dosing, and clinical response for: intranasal corticosteroids; nasal saline/irrigation; antibiotics if bacterial infection suspected; oral corticosteroids when appropriate.
For some guidelines (e.g., EUFOREA), a minimum topical INS trial of ~8 weeks plus appropriate antibiotic therapy and SNOT-22 may be required to demonstrate failure of medical therapy.
Failure of medical therapy is required before considering balloon ostial dilation or FESS; note that balloon dilation is an option only for selected sinuses (frontal, maxillary, sphenoid).

Documentation Required

Required Clinical Documentation

Objective and clinical documentation required for review: requests must include clinical diagnosis supported by objective findings (CT and/or nasal endoscopy), documentation of prior medical therapy and its failure, and symptom correlation to imaging findings.

Clinical diagnosis of CRS or RARS must show appropriate symptoms for ≥12 weeks for CRS or meet RARS episode criteria (e.g., ≥4 discrete episodes/year) as applicable.
Include CT or nasal endoscopy demonstrating sinonasal inflammation, ostial obstruction, mucosal thickening, or other relevant pathology.
Provide prior SNOT-22 score when available and other measures of symptom severity.
Include operative planning details that map CT/endoscopy findings to the sinus(es) proposed for treatment.

Denial Risk

Denial Risk and Common Reasons for Noncoverage

Denial Risk: Procedures may be denied when clinical or objective criteria are not met. Common reasons for denial include insufficient duration of symptoms, lack of documented failure of medical therapy, absence of supportive CT or endoscopic findings, or an indication excluded by the policy (e.g., sinonasal polyps or tumors for balloon dilation).

CRS must have symptoms lasting longer than 12 weeks and persistent symptoms despite specified medical management; otherwise requests may be denied.
Balloon dilation will be denied for sinonasal polyps or tumors and for CRS/RARS not meeting policy criteria.
Lack of objective disease evidence by endoscopy and/or CT after medical therapy may preclude coverage for ESS or balloon dilation.

Documentation Required

Imaging and Symptom Correlation

Imaging and symptom documentation must correlate. Balloon sinus ostial dilation is not appropriate for patients without both sinonasal symptoms and positive CT findings. CT of the sinuses is required before dilation; absence of CT evidence of disease may preclude coverage.

Ensure CT images and reports explicitly document the sinus(es) planned for treatment and show ostial obstruction, mucosal thickening, or opacification as applicable.
Document that patient symptoms (pain, pressure, drainage) localize to the same side(s) as CT findings.

Note

Verify Member Benefits and Plan Governing Terms

Verify Member Benefits: This policy provides general guidance. Coverage decisions must reference the member-specific benefit plan document and any applicable federal or state mandates. If the member-specific plan differs from this policy, the plan document governs.

Before submitting authorization or scheduling a procedure, confirm the member's benefits, plan limits, prior authorization requirements, and coverage exclusions.
Provide documentation to support medical necessity to payers per the member-specific plan requirements.

DefinitionChronic Rhinosinusitis (CRS) is inflammation of the paranasal sinuses persisting >12 weeks with two or more symptoms: mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell.

Requirement for diagnosisInflammation must be documented (polyps, edema, purulent mucus) by endoscopy or radiographic imaging

Minimum symptom durationGreater than 12 weeks

inv-51: Recent CT Scan definition — CT performed within 12 months of the planned procedure.

DefinitionRecent CT Scan = CT performed within 12 months of the planned procedure

PurposeUsed to document extent of disease prior to intervention and to score percent opacification (e.g., Modified Lund-Mackay)

Policy useCT after completion of medical management is required to confirm disease for each sinus to be treated

inv-52: Modified Lund-Mackay Scoring System — quantifies percent opacification per sinus (0–5 scale).

DefinitionModified Lund-Mackay Scoring System quantifies percent opacification per sinus using a 0–5 scale (0=0%, 1=1–25%, 2=26–50%, 3=51–75%, 4=76–99%, 5=100%) with ostiomeatal complex scored 0–2 and total up to 54.

UseApplied to CT imaging to quantify disease severity and document percent opacification for surgical planning

Comparative sensitivityModified and computerized methods may be more sensitive to change than classic Lund-Mackay

inv-53: RARS — Recurrent acute rhinosinusitis definition per AAO-HNS guidance.

DefinitionRecurrent Acute Rhinosinusitis (RARS) is defined as four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals between episodes.

Episode criteriaEach episode should meet ABRS criteria: failure to improve in >=10 days or worsening after initial improvement (double worsening)

ConfirmationConfirming bacterial episodes is preferred; exam during an episode is needed when laboratory confirmation is not available

inv-54: Balloon sinus ostial dilation (BSD / XprESS) — definition and scope of technique.

DefinitionBalloon sinus ostial dilation (BSD / balloon sinuplasty / XprESS) uses balloon catheters to dilate obstructed sinus ostia (frontal, maxillary, sphenoid) and may be performed alone or with other instruments.

IndicationsMay be used for selected patients with CRS or RARS who have failed medical therapy; can be adjunctive to FESS

LimitationsAppropriate for dilation of frontal, maxillary, or sphenoid ostia; not appropriate without both symptoms and positive CT findings

inv-55: Functional endoscopic sinus surgery (FESS) — definition and extent variations.

DefinitionFunctional endoscopic sinus surgery (FESS) comprises endoscopic surgical approaches to open paranasal sinuses; extent ranges from limited to full-house, extended, and radical ESS.

Extent implicationsGreater extent (full-house, radical) generally yields larger improvements in SNOT-22 and lower recurrence/revision rates compared to limited ESS

RoleAppropriate for more extensive disease, complications, or specific CT-confirmed conditions (abscess, mucocele, polyposis, tumor)

inv-56: Maximal medical therapy (MMT) — definition: sustained trial of topical intranasal corticosteroids and saline irrigation with/without adjuncts.

DefinitionMaximal medical therapy (MMT) = sustained trial of topical intranasal corticosteroids and saline irrigation, with or without antibiotics, prior to considering surgery

ExpectationsDocumentation of MMT is required prior to ESS or BSD consideration per guidelines (ICAR-RS, EUFOREA)

AdjunctsOral steroids and antibiotics may be used when appropriate; adenoidectomy considered in children prior to sinus surgery

inv-57: Lund-Mackay score — CT-based scoring system for sinus opacification.

DefinitionLund-Mackay score = a CT-based scoring system for sinus opacification commonly used to quantify disease severity

VariationsClassic Lund-Mackay may be less sensitive to change than modified or computerized 3D/2D methods

Use in policyRecommended for objective documentation of disease severity and surgical planning

inv-58: Balloon dilation vs endoscopic sinus surgery — brief comparative procedural note referenced in literature.

Comparative noteBalloon dilation is a less invasive alternative evaluated against endoscopic sinus surgery in trials and systematic reviews

Evidence summarySystematic reviews/meta-analyses and RCTs provide mixed evidence; BSD may improve short-term QoL in limited disease while FESS is favored for more extensive disease

Policy implicationChoice of procedure should be individualized based on disease extent, objective findings, and failure of medical therapy