CurrentUnitedHealthcarePolicy CS138.S

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

Defines medical necessity criteria, applicable codes, definitions, descriptions, and evidence for balloon sinus ostial dilation (balloon sinuplasty), functional endoscopic sinus surgery (FESS), and related sinus interventions for UnitedHealthcare Community Plan; excludes several state-specific policies.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS138.S

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionDocument completion of full courses of required medical management and provide a recent CT (within 12 months) showing disease extent and specified findings before considering BSD or FESS.

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief (has_material_change=false).

2Main procedural categories (Balloon dilation, FESS)

4Key CT/clinical thresholds listed

17References cited

LimitedPediatric evidence strength

NumerousEvidence quantity

Coverage Summary

Coverage stance: mixed — Balloon Sinus Ostial Dilation (BSD / balloon sinuplasty) and Functional Endoscopic Sinus Surgery (FESS) are covered as medically necessary when specified criteria are met; both procedures have defined medical necessity criteria and procedure-specific limitations, while certain BSD uses and self-expanding absorptive devices are considered unproven/not medically necessary.

Scope summary: policy defines medical necessity criteria (duration and failure of medical therapy, required CT imaging and specific CT findings including percent opacification or Modified Lund-Mackay scoring, ostial obstruction/mucosal thickening, and symptom–imaging concordance), lists applicable CPT codes for BSD and FESS (including 31295–31298 and multiple endoscopic procedure codes), provides definitions (ARS, CRS, RARS, Modified Lund-Mackay, Recent CT), summarizes evidence comparing BSD and FESS, and notes documentation and prior authorization requirements (procedure-specific limitations for BSD and CT timing).

Effective date and review: Effective 08/01/2025; Last review 08/01/2025.

Medically Necessary Criteria

Not Medically Necessary / Unproven

Procedures considered unproven and not medically necessary due to insufficient evidence of efficacy:

Balloon sinus ostial dilation for treating sinonasal polyps or tumors
Balloon sinus ostial dilation for cases of CRS or RARS that do not meet the criteria for medical necessity
Functional Endoscopic Sinus Surgery (FESS) for cases of CRS or RARS that do not meet the criteria for medical necessity
Self-expanding absorptive sinus ostial dilation for evaluating or treating sinusitis and all other conditions

Indications and Eligibility (Guideline Summary)

Indications and eligibility for sinus surgery (per specialty guidelines quoted)

Coverage-relevant indications from cited specialty bodies and consensus documents:

Guideline-aligned indications

ICAR-RS
- Symptoms and objective evidence: Presence of two specific cardinal symptoms for 12 weeks or more>= 12 weeks
- SNOT-22: Preoperative SNOT-22 score of 20 or moreSNOT-22 >= 20

Coding

Applicable CPT codes (procedures referenced in policy)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).
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.

1–10 of 16

1/2

Regulatory/device classification (informational)mixed

LRC	FDA product code: instrument, ENT, manual surgical (includes balloon catheter dilation devices); 510(k)-exempt

Provider Actions & Requirements

Documentation Required

Document medical management failure and CT findings

Providers must document completion of full courses of required medical management and supply recent CT imaging (performed within 12 months) that shows the extent of disease for each sinus to be treated. Required medical therapies: intranasal corticosteroids (and/or oral corticosteroids when appropriate), antibiotic therapy if bacterial infection is suspected, and nasal lavage/irrigation when appropriate. CT documentation specifics: percent of opacification or use of the Modified Lund-Mackay score; presence/absence of ostial (outflow tract) obstruction and mucosal thickening; and any bony changes such as bony remodeling or bony thickening.

Required medical therapies: intranasal corticosteroids ± oral corticosteroids; antibiotics if bacterial infection suspected; nasal lavage/irrigation
Recent CT (within 12 months) obtained after completion of medical management
Document which sinus is diseased and extent using percent opacification or Modified Lund‑Mackay score
CT findings to report: ostial obstruction (outflow tract obstruction) and mucosal thickening
CT findings to report: bony remodeling or bony thickening (if present)

Background, Evidence, and Definitions

Background: FESS is a minimally invasive endoscopic surgical technique to restore sinus drainage and function for medically refractory CRS and related conditions; it allows direct visualization, removal of polyps/infected tissue, and is used for complications of sinusitis (abscess), concha bullosa, mucocele, polyposis with obstruction, and sinonasal tumors. BSD (balloon sinuplasty / balloon catheter dilation) is a minimally invasive technique to dilate sinus ostia (frontal, maxillary, sphenoid) by transnasal or transantral balloon expansion and may be performed standalone or adjunctive to FESS; potential advantages include minimal mucosal damage, less intraoperative bleeding, faster recovery, and less postoperative discomfort.

Investigational / unproven device note: self-expanding absorptive sinus ostial dilation devices (e.g., SinuSys Vent-OS and similar self-expanding systems) are being studied and are considered investigational / not medically necessary due to insufficient evidence of efficacy.

Pediatric note: pediatric evidence for BSD is limited and effectiveness versus ESS cannot be determined from current evidence; the AAO-HNS advises that adenoidectomy should be considered as the first-line surgical procedure in children and strongly considered at least 3 months prior to pediatric sinus surgery when medical management fails.

Source	Key finding
Systematic review (Sinha et al. 2023)	No clinically significant difference in SNOT-20 between BSD and FESS; heterogeneity limits definitive conclusions
Hayes Health Technology Assessment (2019, updated)	Moderate-quality evidence: BSD leads to significant improvements and achieves similar efficacy rates as FESS; pediatric evidence limited
REMODEL trial / meta-analysis (Chandra et al. 2016)	Comparable outcomes between BSD and FESS up to 24 months; technical success ~97.5% and faster recovery with BSD reported
SNOT-22 meta-analysis after ESS (Fu et al. 2023)	ESS associated with mean SNOT-22 improvement of 26.02 (across included studies)
Balloon dilation meta-analysis (Levy et al. 2016)	Long-term within-group improvements in QOL and sinus opacification in selected adult populations; evidence incomplete
Pediatric BSD study (Soler et al. 2016)	50 children: significant SN-5 improvement; 92% achieved MCID ≥ 1.0 at 6 months; no complications reported
Randomized RARS trial (Sikand et al. 2018)	In-office BSD plus medical management superior to medical management alone for RARS on CSS at 24 weeks

Definitions

Thresholds

Revision History

2025-08-01Effective/ReviewLatest

Policy effective / last reviewed

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS138.S

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionDocument completion of full courses of required medical management and provide a recent CT (within 12 months) showing disease extent and specified findings before considering BSD or FESS.

On This Page

Endoscopy or CT: Sinus inflammation and/or purulence on nasal endoscopy

CT evidence: Sinus inflammation on CTCT within 12 months

EUFOREA

Lund-Mackay CT: CT Lund-Mackay score >= 1Lund-Mackay >= 1
Medical trial: Minimum trial of at least 8 weeks of topical intranasal corticosteroid plus either a short course of broad-spectrum/culture-directed systemic antibiotic or a prolonged course of systemic low-dose anti-inflammatory antibiotic>= 8 weeks
SNOT-22 post-treatment: Post-treatment total SNOT-22 score >= 20SNOT-22 >= 20

AAO-HNS and ARS statements on BSD/Balloon dilation

Clinical diagnosis and objective support: Clinical diagnosis of CRS or RARS based on symptoms of sinusitis supported by nasal endoscopy documenting sinonasal abnormality OR mucosal thickening on CT
BSD appropriate uses: Balloon dilation appropriate for selected patients with limited CRS without polyps, RARS with CT evidence of ostial occlusion and mucosal thickening, or as adjunct to FESS

NICE (XprESS): NICE: XprESS may be considered in uncomplicated CRS who do not have severe nasal polyposis; works as well as FESS and often allows faster recovery and local anesthesia

Pediatric notes: Pediatric: evidence insufficient to determine effectiveness of balloon sinuplasty vs ESS; adenoidectomy recommended as first-line surgical procedure for children and should be strongly considered minimum 3 months prior to pediatric sinus surgery when medical management fails

Documentation Required

Symptom correlation with imaging

Document that sinonasal symptoms (for example pain, pressure, or drainage) are present on the same side as the CT findings for the sinus(s) proposed for treatment.

Prior Authorization

Procedure-specific limitation for balloon dilation

Balloon sinus ostial dilation prior authorization requests must specify the CPT code(s) requested and are limited to dilation of the frontal, maxillary, or sphenoid sinuses only. For each sinus to be dilated, provide CT evidence of ostial (outflow tract) obstruction and mucosal thickening.

Affected CPT codes: 31295, 31296, 31297, 31298
Dilation limited to frontal, maxillary, or sphenoid sinuses (policy limitation)
Required CT findings for sinus to be dilated: ostial obstruction and mucosal thickening

Documentation Required

Objective confirmation of sinonasal disease prior to dilation/surgery

Document a clinical diagnosis of CRS or RARS supported by objective findings prior to consideration of BSD or ESS. Objective confirmation may be by nasal endoscopy demonstrating sinonasal inflammation (polyps, edema, or purulence) and/or CT scan showing mucosal disease or opacification.

Nasal endoscopy findings (purulence, edema, polyps) and/or
CT evidence of sinonasal inflammation or opacified sinuses

Documentation Required

Trial of medical therapy

Document a trial and failure of appropriate medical therapy before surgical options are considered. Examples: topical intranasal corticosteroids plus adjuncts; EUFOREA recommends at least an 8‑week trial of topical intranasal corticosteroid plus either a short-course systemic antibiotic or a prolonged low‑dose anti‑inflammatory antibiotic. ICAR‑RS/AAO‑HNS require failure of 'maximal medical therapy' or appropriate medical management.

Document topical intranasal corticosteroid use and duration
Document adjuncts used (e.g., systemic antibiotics when bacterial infection suspected, nasal irrigation)
EUFOREA minimum 8‑week trial requirement for ESS consideration (topical INS + appropriate systemic antibiotic strategy)

Documentation Required

Pediatric pre-surgical consideration

For pediatric cases, document whether adenoidectomy was considered or performed and timing relative to planned sinus surgery. AAO‑HNS pediatric guidance recommends adenoidectomy as a first‑line surgical option for children and that adenoidectomy should be strongly considered at least three months prior to pediatric sinus surgery when medical management fails.

Note if adenoidectomy was attempted and date performed (if applicable)
If not performed, document clinical rationale and whether it was considered at least 3 months prior to planned sinus surgery

Billing Rule

Device/Procedure regulatory note (informational)

Device regulatory information is provided for informational purposes only. Balloon dilation devices are classified under FDA product code LRC (instrument, ENT, manual surgical) and many devices in this category are 510(k)-exempt. FDA clearance or 510(k) summaries (for example SinuSys Vent‑OS 510(k) K133016) do not by themselves determine coverage.

FDA product code: LRC (instrument, ENT, manual surgical)
Example device: SinuSys Vent‑OS (510(k) K133016) — informational only; clearance alone is not a basis for coverage