Prior authorization required; include recent CT and prior medical management

Procedures such as balloon sinus ostial dilation and FESS (CPT codes: 31295–31298, 31240, 31253–31259, 31267, 31276, 31287–31288, 31299) require prior authorization and review. Prior authorization requests must include recent CT imaging (CT within 12 months) and documentation of prior medical management to support medical necessity for the requested procedure codes.

• Applicable CPT codes: 31295, 31296, 31297, 31298, 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31299
• Include CT obtained after completion of medical management and documentation of which sinus is diseased and extent (e.g., percent opacification or Modified Lund‑Mackay score)

Objective imaging or endoscopic confirmation required before balloon dilation

Before performing balloon sinus dilation, establish a clinical diagnosis of CRS or RARS supported by objective findings: nasal endoscopy demonstrating sinonasal abnormality OR CT showing mucosal thickening/opacification. CT scanning of the sinuses is required prior to balloon dilation.

• Nasal endoscopy documenting sinonasal abnormality or mucosal thickening on CT can substantiate the diagnosis
• CT scanning of the sinuses is a requirement before balloon dilation can be performed

Verify failed medical therapy and include CT imaging with prior authorization

Prior authorization submissions must document failure of appropriate medical therapy and include objective CT imaging demonstrating disease (CT without contrast preferred for surgical planning). Include CT imaging obtained after completion of medical management and documentation of which sinus and extent of disease.

• Document failed appropriate medical therapy (e.g., intranasal corticosteroids, antibiotics when indicated, nasal irrigation)
• Provide CT evidence obtained after medical therapy showing disease extent and features (bony remodeling, opacification, ostial obstruction, mucosal thickening)

Preauthorization must document imaging and failure of maximal medical therapy

Preauthorization must show CT imaging consistent with sinonasal disease and documentation that maximal medical therapy was attempted and failed (for example, topical intranasal corticosteroids plus systemic antibiotic or prolonged low‑dose antiinflammatory antibiotic when indicated). Include symptom duration, symptom concordance with imaging, and any relevant symptom scores.

• CT evidence of disease (CT without contrast preferred) and identification of affected sinus and extent
• Document failure of maximal medical therapy (minimum trial descriptions where applicable, e.g., 8 weeks topical intranasal steroid plus antibiotic)
• Include symptom duration (≥12 weeks for CRS) and symptom‑to‑imaging concordance; include SNOT‑22 when available

Document failure of medical management prior to surgery

Demonstrate failure of medical management in the medical record before surgery: document full courses of intranasal corticosteroids (and oral corticosteroids when appropriate), antibiotics if bacterial infection is suspected, and nasal lavage/irrigation as applicable.

• Medical record must show recent medical management with full courses of listed therapies prior to considering surgery
• Include whether antibiotics were prescribed only when significant purulent discharge was present per guideline recommendations

Trial evidence: ESS showed benefit after failed medical therapy

Randomized trial evidence supports ESS superiority over prolonged low‑dose clarithromycin or placebo after failure of appropriate medical therapy; intranasal medications and saline irrigation were continued as baseline therapy in that trial.

• Philpott et al. (2025) randomized 514 participants who had failed appropriate medical treatment and demonstrated ESS improved SNOT‑22 at 6 months compared with clarithromycin or placebo

Documented trial of medical therapy required

Document a tailored trial of medical therapy in the record prior to surgery: intranasal corticosteroids, nasal saline irrigation, and targeted antibiotics when clinically indicated; document durations and response.

• Record intranasal corticosteroid use and duration, saline irrigation, and any antibiotic courses (indication and duration)
• Document clinical response or persistence of symptoms despite therapy

Document minimum 8‑week medical trial when indicated

When applicable, document a minimum medical trial prior to ESS: at least 8 weeks of topical intranasal corticosteroid PLUS either a short course of broad‑spectrum/systemic antibiotic or a prolonged low‑dose antiinflammatory antibiotic per EUFOREA guidance.

• EUFOREA: minimum 8‑week topical intranasal corticosteroid plus short systemic antibiotic or prolonged low‑dose antiinflammatory antibiotic for uncomplicated CRSsNP
• Record posttreatment symptom score (SNOT‑22 ≥20 when used)

Maintain complete medical records to support medical necessity

Medical records must contain relevant history, physical exam findings, and results of diagnostic tests or procedures that fully support medical necessity; records must be legible and available upon request.

• Include history of symptom duration (≥12 weeks for CRS), symptom details, physical exam, nasal endoscopy findings, and CT results
• Maintain records legibly and make available for review

Provide objective endoscopic or CT evidence to support procedure

Objective evidence is required to support balloon sinus dilation or FESS: nasal endoscopy documenting sinonasal abnormality and/or CT showing mucosal thickening, ostial obstruction, opacification, or bony changes.

• Nasal endoscopy findings (edema, purulence, polyps) or CT findings (mucosal thickening, ostial obstruction, bony remodeling/thickening, opacified sinus)
• Document which sinus is affected and extent (percent opacification or CT scoring)

Document symptom duration, symptoms, and objective inflammation

Required diagnostic documentation includes symptom duration (≥12 weeks for CRS), at least two CRS symptoms, and objective evidence of sinonasal inflammation via anterior rhinoscopy, nasal endoscopy, or CT; include a fine‑cut non‑contrast CT for surgical planning when applicable.

• Document duration ≥12 weeks and ≥2 cardinal CRS symptoms (nasal drainage, obstruction, facial pain/pressure, decreased smell)
• Include anterior rhinoscopy or nasal endoscopy findings and obtain fine‑cut, non‑contrast CT for surgical planning

Include CT scoring and symptom measures in diagnostic documentation

Document CT evidence using CT without contrast when possible and include a validated CT scoring method (Lund‑Mackay or alternative such as ostiomeatal complex or Zinreich) and symptom measures (e.g., SNOT‑22) as part of preoperative evaluation.

• Record Lund‑Mackay score or alternate validated CT scoring and specify affected sinuses and extent
• Include preoperative SNOT‑22 when used and CT protocol (fine‑cut, non‑contrast)

Inadequate documentation may trigger denial or additional information requests

Insufficient or missing documentation of medical necessity (history, exam, diagnostic test results) may trigger a denial or request for additional information.

• Denial risk if records lack documentation of prior medical management, objective imaging, or clinical findings supporting CRS/RARS
• Ensure documentation is legible and available upon request to avoid delays or denial

Do not perform balloon dilation without sinonasal symptoms and positive CT

Balloon dilation is not appropriate for patients without sinonasal symptoms and positive CT findings; performing dilation without required CT evidence may lead to denial.

• CT scanning is a requirement before balloon dilation and balloon dilation is not appropriate when CT does not show disease despite symptoms
• Do not perform BSD for headaches or sleep apnea absent CRS criteria

Lack of objective verification can lead to denial

Absence of objective verification of CRS (no CT, endoscopy, or clinical documentation) may lead to denial or noncoverage of the requested procedure.

• Prior authorization reviewers will look for CT or endoscopy demonstrating inflammation or mucosal disease
• Document symptom‑imaging concordance and objective findings to support surgical candidacy

Denial triggers: missing imaging, therapy failure, or inadequate symptom duration

Coverage may be denied if required objective imaging is missing, maximal medical therapy failure is not documented, or adequate symptom duration is not shown (e.g., lack of CT evidence, Lund‑Mackay score, or SNOT‑22 where indicated).

• Denial triggers include missing CT evidence obtained after medical therapy, absent documentation of failure of maximal medical therapy, or missing symptom duration/score documentation (≥12 weeks, Lund‑Mackay, SNOT‑22)
• Include CT performed within 12 months and document post‑medical‑therapy imaging to meet criteria