Sinus Procedures (for Louisiana Only)
State-specific Louisiana medical policy governing coverage and medical necessity criteria for balloon ostial dilation and functional endoscopic sinus surgery (FESS), and the coverage stance for self‑expanding absorptive sinus ostial dilation; affects providers treating Louisiana Medicaid/UnitedHealthcare Community Plan members.
Policy retired and Louisiana plan membership disenrolled on Apr. 1, 2026.
Updated clinical evidence and references in the supporting information.
Coverage and Medical Necessity Criteria
Medically necessary - Balloon ostial dilation and FESS (Louisiana-specific)
Covered when ALL of the following are met:
From state-specific criteria
Therapies may be sequential or overlapping
One of the listed tests required
Self-expanding absorptive sinus ostial dilation — Coverage stance
Coverage stance:
Example device: SinuSys Vent-OS
Balloon ostial dilation and functional endoscopic sinus surgery (FESS) are not covered and are considered not medically necessary in specific situations. These include when sinonasal symptoms exist without objective evidence of sinonasal disease demonstrated by nasal endoscopy or computed tomography; when procedures are performed for the treatment of obstructive sleep apnea and/or snoring but the chronic rhinosinusitis criteria are not met; and when procedures are performed for the treatment of headaches but the chronic rhinosinusitis criteria are not met. Additionally, balloon ostial dilation alone is not covered when sinonasal polyps are present.
Self-expanding absorptive sinus ostial dilation (for example, devices that expand by absorbing moisture within the sinus ostia) is considered unproven and not medically necessary for evaluating or treating sinusitis and all other conditions due to insufficient evidence of efficacy. More generally, procedures performed without objective endoscopic or computed tomography evidence of sinonasal inflammation are not considered medically necessary.
Procedure Codes and Key Parameters
| 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. |
Documentation, Authorization, and Denial Triggers
Prior Authorization Required
Prior authorization may be required per plan rules for listed sinus procedure CPT codes.
- Prior authorization may be required for balloon ostial dilation and functional endoscopic sinus surgery per member plan benefits and rules.
Maximal Medical Therapy Required
Providers must document a trial of maximal medical therapy prior to surgical intervention. Maximal medical therapy includes saline nasal irrigation and intranasal corticosteroids for at least six weeks, treatment of concomitant allergic rhinitis if present, and when applicable, an approved biologic for at least six weeks. A complete course of appropriate antibiotics should be given when an acute bacterial infection is suspected.
- Saline nasal irrigation ≥ 6 weeks
- Nasal corticosteroids ≥ 6 weeks
- Approved biologics, if applicable, ≥ 6 weeks
- Complete course of antibiotics when acute bacterial infection is suspected
- Treatment of concomitant allergic rhinitis, if present
Documentation Required
Document chronic rhinosinusitis (CRS) present ≥ 12 weeks with ≥ 2 qualifying sinonasal symptoms (facial pain/pressure, hyposmia/anosmia, nasal obstruction, mucopurulent nasal discharge) and objective evidence of sinonasal inflammation by nasal endoscopy or CT. Include documentation that maximal medical therapy (see above) was attempted and failed prior to surgical intervention.
- CRS duration ≥ 12 weeks
- At least two symptoms: facial pain/pressure; hyposmia/anosmia; nasal obstruction; mucopurulent nasal discharge
- Objective evidence by nasal endoscopy or computed tomography
- Documentation of completion and persistence of maximal medical therapy
Triggers for Denial
Claims may be denied when sinonasal symptoms lack objective endoscopic or CT evidence, when CRS duration or symptom count criteria are not met, or when documentation does not show completion of maximal medical therapy prior to surgery. Balloon ostial dilation is not covered when sinonasal polyps are present. Procedures performed for indications such as obstructive sleep apnea, snoring, or headaches without meeting criteria are not medically necessary.
- No objective endoscopic or CT evidence of sinonasal disease — denial trigger
- CRS duration < 12 weeks or fewer than 2 qualifying symptoms — denial trigger
- Lack of documented trial and failure of maximal medical therapy — denial trigger
- Balloon ostial dilation when sinonasal polyps present — not covered
- Procedures for OSA, snoring, or headaches without meeting criteria — not medically necessary
Clinical Background
Chronic rhinosinusitis (CRS) is characterized by persistent sinonasal inflammation and symptoms lasting at least 12 weeks. For patients who do not improve after a documented trial of maximal medical therapy (including saline nasal irrigation and nasal corticosteroids for at least 6 weeks, antibiotics when indicated, treatment of allergic rhinitis, and biologics if applicable), surgical options may be considered. Surgical interventions include balloon ostial dilation and functional endoscopic sinus surgery (FESS), which are intended to restore sinus ventilation and drainage in patients with objective evidence of sinonasal inflammation on nasal endoscopy or computed tomography.
Definitions and Operational Terms
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