CurrentUnitedHealthcarePolicy CS138PA.Q

Sinus Surgeries and Interventions (for Pennsylvania Only)

UnitedHealthcare medical policy (Pennsylvania-only) describing coverage criteria, definitions, applicable codes, clinical rationale, and evidence for balloon sinus ostial dilation (BSD), functional endoscopic sinus surgery (FESS), self-expanding absorptive dilation, and related sinus procedures. This is Part 1 of 3 and includes indications, definitions, clinical evidence and CPT code lists.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions (for Pennsylvania Only)

Policy CodePolicy CS138PA.Q

Change TypeRevised clinical evidence and references

Effective DateAug 1, 2025

Next Review Date

Key ActionObtain and document completion of full courses of appropriate medical therapy and a recent CT after medical management before considering BSD or FESS.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information.

1State-specific policy (PA only)

>=4RARS episode threshold

12CRS duration threshold (weeks)

multipleGuideline sources cited