CurrentUnitedHealthcarePolicy CS138OH.C

Sinus Surgeries and Interventions (for Ohio Only)

Ohio-specific UnitedHealthcare medical policy CS138OH.C governing coverage and medical necessity criteria for balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS) for various sinuses, and self-expanding absorptive sinus ostial dilation, including pediatric and adult criteria, definitions, and applicable CPT procedure codes (reference list).

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions (for Ohio Only)

Policy CodePolicy CS138OH.C

Change TypeClarified & Added criteria; Unproven designation affirmed

Effective DateSep 1, 2025

Next Review Date

Key ActionProvide prior authorization documentation consistent with InterQual CP and Ohio Administrative Code 5160-101, including recent CT after medical management, sinus-specific disease extent (percent opacification or Modified Lund-Mackay), and documentation of prior medical therapy.

POLICY UPDATE CHANGES

Replaced language to specify FESS is medically necessary for the sphenoid sinus when listed conditions are confirmed on CT and clarified unproven scope for the sphenoid sinus.

Added pediatric-specific criteria indicating balloon sinus ostial dilation and/or FESS are proven and medically necessary when CRS or RARS criteria and CT confirmation requirements are met.

Clarified CT findings required and documentation of extent of disease including percent opacification or Modified Lund-Mackay Scoring System.

Affirmed that self-expanding absorptive sinus ostial dilation is unproven and not medically necessary.

SeveralCovered Indication Groups

Coverage Summary

This is Ohio-specific UnitedHealthcare Medical Policy CS138OH.C (effective 2025-09-01) covering surgical management of chronic and recurrent rhinosinusitis. The policy addresses balloon sinus ostial dilation (BSD) and functional endoscopic sinus surgery (FESS) — with BSD and FESS described as proven and medically necessary for specified adult and pediatric indications when the listed clinical and imaging criteria are met — and also covers procedural coding and FDA device context. The policy additionally addresses self-expanding absorptive sinus ostial dilation devices, which are categorized as unproven and not medically necessary. Headline policy metrics (coverage groups, unproven categories, evidence strength, guideline dependencies) are summarized in the policy statistics and status. Effective date: September 1, 2025.

Adults — Balloon Sinus Ostial Dilation (BSD)

Members 18 Years of Age and Older — Balloon sinus ostial dilation

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ALL of the following

Balloon sinus ostial dilation is proven and medically necessary in certain circumstances.
Policy defers to InterQual CP: Procedures, Balloon Ostial Dilation for clinical coverage specifics. External criteria; policy defers to InterQual for specifics.

Adults — Balloon Sinus Ostial Dilation (BSD)

Appropriate indications, required medical management, imaging, documentation, limitations, contraindications, and pediatric exclusions for Balloon Sinus Ostial Dilation (BSD/Balloon Sinuplasty) and Functional Endoscopic Sinus Surgery (FESS).

ALL of the following

Appropriate Indications for Balloon Sinus Ostial Dilation (BSD/Balloon Sinuplasty)
- Chronic Rhinosinusitis (CRS) lasting longer than 12 weeks with persistent symptoms despite recent medical management; and confirmation on recent CT scan for each sinus to be treated (CT obtained after medical management) with documentation of disease extent (percent opacification or Modified Lund-Mackay) and CT findings such as bony remodeling, bony thickening, opacified sinus, ostial obstruction (outflow tract obstruction) and mucosal thickening; and sinonasal symptoms (pain, pressure, or drainage) present on the same side as CT findings.
- Recurrent Acute Rhinosinusitis (RARS): four or more episodes per year with distinct symptom-free intervals; sinonasal symptoms present on the same side as CT findings; and recent CT showing ostial obstruction and mucosal thickening in the sinus to be dilated.
Appropriate Indications for Functional Endoscopic Sinus Surgery (FESS)

Adults — Functional Endoscopic Sinus Surgery (FESS)

Pediatric — BSD and FESS

Unproven / Not Medically Necessary Indications

Rationale: the policy differentiates proven procedures from unproven ones based on the available evidence. BSD and FESS have randomized trials, systematic reviews, and guideline support for selected indications, but evidence is heterogeneous. In contrast, self-expanding absorptive devices are supported only by small pilot studies with no control or comparative data and therefore lack sufficient evidence of efficacy; the policy cites limited pilot experience and absence of comparative outcomes as the basis for deeming these devices unproven.

Procedure, Imaging, and Device Codes

Applicable Procedure CPT Codes (reference list)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

Imaging requirement (pre-procedure)mixed

Non-contrast CT of the sinuses — see policy

FDA product/device informationmixed

LRC	FDA product code: instrument, ENT, manual surgical (includes balloon catheter dilation devices)

Provider Actions and Authorization Requirements

Prior Authorization

Refer to InterQual criteria for authorization

Medical necessity determinations for adult Balloon Sinus Dilation (BSD) and many Functional Endoscopic Sinus Surgery (FESS) indications are determined using InterQual CP criteria. Providers requesting prior authorization must supply documentation consistent with InterQual and Ohio Administrative Code 5160-101 to support the medical necessity request.

Documentation Required

CT imaging and documentation requirements

Required CT imaging and documentation must be submitted for each sinus planned for treatment. CT images must be obtained after completion of the recent medical management described in this policy and within 12 months of the planned procedure. Documentation must clearly identify which sinus or sinuses have disease and quantify extent of disease.

Timing: CT images obtained after completion of medical management and considered recent when performed within 12 months of the planned procedure.

Background, Evidence Summary, and Definitions

Background: surgical management of medically refractory chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) includes FESS — a minimally invasive, mucosal-sparing set of techniques to open sinus ostia and remove obstructing tissue — and balloon sinus ostial dilation (BSD), which may be performed as a standalone or as a hybrid adjunct to FESS. FESS is proven and medically necessary for multiple sinuses (ethmoid, frontal, maxillary) when policy criteria are met and for the sphenoid sinus in specified CT-confirmed conditions; BSD is proven and medically necessary for selected frontal, maxillary, or sphenoid dilations per the policy criteria. Self-expanding absorptive sinus ostial dilation devices (e.g., osmotic expansion devices) are described in the policy as investigational and unproven pending larger comparative studies.

Citation/Label	Key finding
Hayes HTA (adults)
Moderate-quality evidence: BSD yields significant improvements similar to FESS; no clear superiority; limited definitive patient selection criteria (Hayes 2019, updated 2022).
Sinha 2023 systematic review
No clinically significant difference in SNOT-20 outcomes between BSD and FESS; heterogeneity limits firm conclusions.
Multiple RCTs/series (e.g., REMODEL and others)
Randomized trials and meta-analyses report comparable outcomes for BSD vs FESS up to 24 months with similar symptom improvements and recovery advantages for BSD in some reports.
Randomized sham-controlled trial (Laury et al. 2018)
In patients with pressure-related sinus headache without CT mucosal disease, no difference between active BSD and placebo; both improved from baseline.
Soler et al. pediatric BSD (single-arm)
Single-arm pediatric study showed significant SN-5 improvement at 6 months; 92% achieved the MCID ≥1.0; no comparison group.
Levy 2016 systematic review
Long-term within-group QOL improvements after BCD documented but evidence incomplete; no consistent superiority versus ESS.
Fu 2023 meta-analysis (ESS SNOT-22)
Pooled mean SNOT-22 change after ESS = 26.02 (statistically significant), demonstrating consistent PROM improvements with ESS.
Modified Lund-Mackay concordance (Likness et al. 2014)
OMC method CCC 0.915; Zinreich 0.904; Lund-Mackay 0.824 — supporting use of modified scoring to document extent/opacification on CT.
Self-expanding device pilot (Hathorn et al. 2014)
Pilot study (n=12) showed device could be inserted and dilate ostia with patency at follow-up but was small and uncontrolled; evidence insufficient to support efficacy.

Term	Definition
Acute Rhinosinusitis (ARS)
ARS: inflammation of nose and paranasal sinuses with sudden onset purulent drainage plus nasal obstruction or facial pain/pressure/fullness for up to 4 weeks. (Rosenfeld et al., 2015).
Chronic Rhinosinusitis (CRS)
CRS: inflammatory process of paranasal sinuses >12 weeks with ≥2 symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, decreased smell) plus documented inflammation (polyps, edema, purulence, or radiographic inflammation).
Recurrent Acute Rhinosinusitis (RARS)
RARS: ≥4 episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals; confirmation preferred by lab or exam during an episode.
Modified Lund-Mackay Scoring System
CT-based scoring per sinus (0-5) by percent opacification (0=0%, 1=1–25%, 2=26–50%, 3=51–75%, 4=76–99%, 5=100%); ostiomeatal complex 0–2; total max 54. Useful to document extent of disease.
Recent CT Scan
Recent CT Scan: CT performed within 12 months of the planned procedure for purposes of this policy.
Functional Endoscopic Sinus Surgery (FESS)
FESS: minimally invasive, mucosal-sparing surgical technique to treat medically refractory CRS or RARS.
BSD/BCD/BCS
Balloon sinus ostial dilation / balloon catheter dilation / balloon catheter sinuplasty: balloon-based technique to dilate sinus ostia; may be stand-alone or adjunct to FESS.
FESS/ESS
Functional endoscopic sinus surgery / endoscopic sinus surgery (FESS/ESS): surgical opening and drainage of sinus air cells and ostia under direct visualization; may remove polyps/infected tissue.
MMT (Maximal Medical Therapy)
MMT: medical management including intranasal corticosteroids ± oral corticosteroids when appropriate, antibiotics if suspected bacterial infection, and nasal lavage/irrigation.

Appropriate Use and Contraindications

Revision History

2025-09-01policy_revisionLatest

Replaced broader language to specifically reference the sphenoid sinus: FESS is proven and medically necessary for the sphenoid sinus when listed conditions are confirmed on CT; FESS for the sphenoid sinus is unproven and not medically necessary for other conditions due to insufficient evidence.

2025-09-01policy_additionLatest

Added pediatric-specific criteria: Balloon sinus ostial dilation and/or FESS are proven and medically necessary when CRS or RARS criteria and CT confirmation requirements (including CT after medical management, documentation of affected sinus and extent via percent opacification or Modified Lund-Mackay) are met; balloon dilation limited to frontal, maxillary, or sphenoid sinuses in pediatrics.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions (for Ohio Only)

Policy CodePolicy CS138OH.C

Change TypeClarified & Added criteria; Unproven designation affirmed

Effective DateSep 1, 2025

Next Review Date

On This Page

FESS for sphenoid sinus when CRS >12 weeks with persistent symptoms despite medical management (intranasal corticosteroids ± oral steroids, antibiotics if bacterial infection suspected, nasal lavage/irrigation if appropriate) and recent CT after medical management documenting disease for the sinus to be treated; or when CT confirms symptomatic mucocele, polyposis with obstructive symptoms, sinonasal tumor, complications of sinusitis (e.g., abscess), or symptomatic concha bullosa.

Imaging and Documentation Requirements

Recent CT scan (performed within 12 months of planned procedure) obtained after completion of medical management described above for each sinus to be treated.
Documentation must identify which sinus has disease and extent of disease (percent opacification or use of Modified Lund-Mackay Scoring System).
CT findings must include one or more of: bony remodeling, bony thickening, opacified sinus, ostial obstruction (outflow tract obstruction) and mucosal thickening.
Sinonasal symptoms (pain, pressure, or drainage) must be present on the same side as CT scan findings of rhinosinusitis.

Not Appropriate / Contraindications for Balloon Dilation

Sinonasal polyps or tumors — balloon sinus ostial dilation is unproven and not medically necessary for treatment of polyps or tumors.
Cases of CRS or RARS that do not meet the stated clinical, medical management, and imaging criteria — balloon dilation or FESS are not medically necessary for these cases.
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.

Pediatric Considerations (Members Under 18)

For members under 18, BSD and/or FESS are proven and medically necessary when one or more of the following are present: CRS >12 weeks with persistence despite recent medical management (intranasal corticosteroids ± oral corticosteroids, antibiotics if bacterial infection suspected, nasal lavage/irrigation if appropriate) and recent CT after medical management documenting disease per sinus with percent opacification or Modified Lund-Mackay scoring; CT findings include bony remodeling, bony thickening, opacified sinus, ostial obstruction and mucosal thickening; and sinonasal symptoms present on same side as CT findings.
For pediatric BSD specifically, dilation is limited to the frontal, maxillary, or sphenoid sinuses. For RARS in pediatrics, four or more episodes per year with CT evidence: for BSD ostial obstruction and mucosal thickening in the sinus to be dilated; for FESS, for maxillary/frontal/sphenoid both ostial obstruction and mucosal thickening, and for ethmoid mucosal thickening.
BSD and FESS are unproven and not medically necessary for pediatric sinonasal polyps, tumors, or CRS/RARS cases not meeting the above criteria.

Documentation Required

Objective documentation prior to BSD or FESS

Document recent medical management prior to BSD or FESS and include details of duration and response. Prior to surgical intervention, evidence of appropriate medical therapy is required.

Intranasal corticosteroids (and/or a trial of oral corticosteroids when appropriate) with documentation of dates and adherence.
Antibiotic therapy when bacterial infection is suspected; include course, indication, and response.
Nasal lavage/irrigation if appropriate and documented use.
If applicable, documentation of multiple medical therapy attempts and lack of sustained clinical improvement.

Denial Risk

Procedures considered unproven (denial risk)

Procedures, devices, or uses that lack sufficient evidence of efficacy are considered denial risks and may be denied as not medically necessary.

Self-expanding absorptive sinus ostial dilation devices (unproven; not medically necessary).
Balloon sinus dilation for sinonasal polyps or tumors, or for CRS/RARS cases that do not meet the documented clinical and imaging criteria in this policy.
Functional Endoscopic Sinus Surgery (FESS) when the case does not meet the clinical, medical management, and CT imaging criteria required by this policy.

Billing Rule

Balloon dilation sinus limitation

Balloon dilation is limited to the frontal, maxillary, or sphenoid sinuses and must be billed to reflect the specific sinus(es) dilated.

Balloon dilation limited to: frontal sinus, maxillary sinus, or sphenoid sinus only — document which sinus was dilated.
Do not bill balloon dilation for ethmoid sinuses; ethmoid interventions are typically reported as FESS/ethmoidectomy per coding guidance.

Prior Authorization

Prior authorization implied for surgical procedures

Policy review for BSD or FESS generally requires prior authorization. Requests should include documentation of clinical indications, recent CT imaging, and failure of appropriate prior medical therapy consistent with InterQual CP and Ohio Administrative Code 5160-101.

2025-09-01policy_clarificationLatest

Clarified required CT findings and documentation: CT images must be obtained after completion of medical management; documentation must specify which sinus and extent of disease including percent opacification or Modified Lund-Mackay scoring; acceptable CT findings include bony remodeling, bony thickening, opacified sinus, ostial obstruction and mucosal thickening; symptoms must be on same side as CT findings.