CurrentUnitedHealthcarePolicy CS138.S

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

Policy governs medical necessity criteria, definitions, clinical evidence, and applicable procedure codes for balloon sinus ostial dilation (balloon sinuplasty), Functional Endoscopic Sinus Surgery (FESS), and related sinus interventions; excludes certain states where separate state-specific policies apply.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS138.S

Change TypeNebraska application addedreferences updated

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument completion of recent medical management (antibiotics if bacterial infection suspected, intranasal/oral corticosteroids when appropriate, and nasal lavage/irrigation) and provide recent CT images obtained after medical management showing disease extent and CT findings for each sinus to be treated.

SourceLink

POLICY UPDATE CHANGES

Application Nebraska: Added language indicating this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.

Supporting Information section updated to reflect current Clinical Evidence and References.

>12wDuration threshold for CRS

>=4Episodes/yr threshold for RARS

31295-31299Key CPT codes referenced

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Nebraska exception added

MultipleReferences updated

Coverage Summary

Policy subject: Sinus Surgeries and Interventions (Balloon sinus ostial dilation and Functional Endoscopic Sinus Surgery [FESS]). Scope: This policy governs medical necessity criteria, definitions, clinical evidence, and applicable procedure codes for balloon sinus ostial dilation (balloon sinuplasty) and FESS, including stand-alone and hybrid procedures. State exclusions: Does not apply to Nebraska; refer to the Nebraska-specific policy version. Benefit coverage is subject to applicable federal, state, or contractual requirements and applicable laws which govern in the event of conflict. Effective date: August 1, 2025. Policy number: CS138.S.

Quick facts / thresholds

CRS duration threshold> 12 weeks

RARS episodes threshold>= 4 episodes/year (distinct symptom-free intervals)

Recent CT validityCT performed within 12 months of planned procedure

Key CPT codes referenced31295-31299, 31240-31288

Nebraska exceptionThis policy does not apply to Nebraska; refer to Nebraska-specific policy

References / updatesSupporting information and references updated (policy history)

Medical-Necessity Criteria

Medically Necessary Indications for Balloon Sinus Ostial Dilation and/or FESS

Covered when ANY of the following are met:

ANY of the following

Chronic Rhinosinusitis (CRS)
- Symptoms consistent with CRS persisting for longer than 12 weeks
- - Antibiotic therapy when bacterial infection is suspected
  - Intranasal corticosteroids (and/or oral corticosteroids when appropriate)
  - Nasal lavage/irrigation when appropriate

Evidence-based Considerations & Definitions

Evidence-based coverage considerations summary: Computerized CT analysis (3D volumetric) provides the most comprehensive, objective, and reproducible measurement of CRS disease severity and is very sensitive to treatment-induced change; a 2D coronal image through the ostiomeatal complex (OMC) may be a valid, user-friendly surrogate representative of CRS severity in all sinuses. Current evidence is insufficient to support self-expanding absorptive sinus ostial dilation devices due to limited literature, small sample sizes, and lack of comparative data. Balloon catheter dilation devices are classified under the FDA product code LRC; some devices have 510(k) clearances (for example, the SinuSys Vent-OS Sinus Dilation System for adults).

Evidence	Summary
Systematic review (Sinha et al. 2023)
No clinically significant difference in SNOT-20 outcomes between BSD and FESS; heterogeneity limits conclusions
Hayes HTA (2019, updated 2022)
Moderate-quality evidence suggests BSD leads to significant improvements and similar efficacy rates as FESS; limited definitive patient selection criteria
Lin's concordance correlation (OMC vs 3D volumetric)
0.915 (best correlation)
Zinreich method concordance
0.904
Lund-Mackay method concordance
0.824 (lower agreement) and posttreatment 0.545 (moderate)
Self-expanding device study success rate
Device insertion success 100% (19/19 MSOs), 93% patency at 3 months (14/15 MSOs)

Definitions:

• Acute Rhinosinusitis (ARS): Inflammation of the mucosa of the nose and paranasal sinuses with sudden onset purulent nasal drainage and nasal obstruction/facial pain of up to 4 weeks duration.

• Chronic Rhinosinusitis (CRS): Inflammation persisting for more than 12 weeks with ≥2 symptoms (eg, nasal obstruction, mucopurulent drainage, facial pain/pressure, decreased sense of smell) and documented inflammation (polyps, edema, purulent mucus, or radiographic imaging).

• Recurrent Acute Rhinosinusitis (RARS): Four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals; each episode should meet ABRS diagnostic criteria.

• Recent Computed Tomography (CT) Scan: A CT is considered recent when performed within 12 months of the planned procedure.

• Functional Endoscopic Sinus Surgery (FESS): A minimally invasive, mucosal-sparing surgical technique to treat medically refractory CRS with or without polyps or RARS.

Coding

Covered / referenced CPT codes for sinus proceduresCPTCovered

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

FDA product code referencedmixed

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

Procedure / general categories discussed (no explicit CPT/HCPCS listed in this part)mixed

No codes listed

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization expectation

Medical records documentation may be required to assess whether the member meets clinical criteria for coverage. Inclusion of codes in the policy does not guarantee coverage or payment. Providers should be aware that medical records documentation may be requested during review.

Medical records may be required for review
Inclusion of codes does not guarantee coverage/payment

Documentation Required

Medical management documentation

Document completion of recent medical management before surgery, including: a full course of antibiotics when bacterial infection is suspected; intranasal corticosteroids (and/or oral corticosteroids when appropriate); and nasal lavage/irrigation. Medical records showing completion of these therapies may be required for review to confirm failure of medical management.

Antibiotic therapy if bacterial infection is suspected

Background

Background: Chronic rhinosinusitis (CRS) is rhinosinusitis that persists for longer than 12 weeks; recurrent acute rhinosinusitis (RARS) is defined as ≥4 episodes/year of acute bacterial rhinosinusitis with distinct symptom-free intervals. Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive technique to open and drain sinus air cells and ostia under direct visualization, with removal of polyps or infected tissue as indicated. Balloon sinus ostial dilation (balloon sinuplasty) uses a catheter-mounted balloon to dilate sinus ostia (frontal, maxillary, or sphenoid) and can be performed as a stand-alone procedure or combined with FESS as a hybrid approach. Self-expanding absorptive sinus ostial dilation devices (for example, the SinuSys Vent-OS system) have been cleared by the FDA but are under investigation; current evidence is insufficient to establish safety and effectiveness. Benefit coverage is governed by applicable federal, state, and contractual requirements, and medical records documentation may be required to assess whether clinical criteria for coverage are met.

Definitions & Thresholds

Definitions & thresholds

ARS (Acute Rhinosinusitis)Inflammation with purulent drainage plus obstruction or facial pain up to 4 weeks

CRS (Chronic Rhinosinusitis)Inflammation persisting >12 weeks with ≥2 symptoms and documented inflammation

RARS (Recurrent Acute Rhinosinusitis)4 or more episodes/year of ABRS with distinct symptom-free intervals

Recent CTCT considered recent if performed within 12 months of planned procedure

FESSMinimally invasive, mucosal-sparing surgical technique for medically refractory CRS or RARS

OMC (Ostiomeatal Complex)Anatomic region evaluated on imaging for CRS severity

510(k)

Revision History

10/01/2025material changeLatest

Application Nebraska: Added language indicating this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.

08/01/2025archival/revised supporting information

Supporting Information section updated to reflect current Clinical Evidence and References; archived previous policy version CS138.R.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS138.S

Change TypeNebraska application addedreferences updated

Effective DateAug 1, 2025

Next Review Date

SourceLink

On This Page

Confirmation of sinus inflammation on a recent CT scan (performed within 12 months of planned procedure) for each sinus to be treated, with documentation of which sinus is affected and extent of disease (eg, percent opacification or Modified Lund-Mackay score)

CT findings after completion of the medical management above demonstrating one or more of: bony thickening, bony remodeling, opacified sinus, ostial (outflow tract) obstruction, or mucosal thickening

Sinonasal symptoms (pain, pressure, or drainage) present on the same side as CT findings

Recurrent Acute Rhinosinusitis (RARS)

Four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals between episodes
Documentation that each episode meets ABRS diagnostic criteria (eg, failure to improve within 10 days, double worsening, or confirmed/presumed bacterial infection)
Sinonasal symptoms present on the same side as CT scan findings
Recent CT evidence of ostial obstruction (outflow tract obstruction) and mucosal thickening in the sinus to be treated

FESS-specific CT-confirmed indications

CT-confirmed ostial (outflow tract) obstruction in the sinus to be treated
For maxillary, frontal, or sphenoid sinuses: mucosal thickening in the sinus to be treated
For ethmoid sinus: mucosal thickening present
Complications of sinusitis such as abscess
Symptomatic mucocele
Symptomatic concha bullosa
Polyposis with obstructive symptoms
Sinonasal tumor

Not Medically Necessary / Unproven Indications

Not medically necessary / unproven when ANY of the following apply:

ANY of the following

Balloon sinus ostial dilation for cases of CRS or RARS that do not meet the criteria listed in the medically necessary section
Balloon sinus ostial dilation for treatment of sinonasal polyps or tumors
Functional Endoscopic Sinus Surgery (FESS) for cases of CRS or RARS that do not meet the criteria listed in the medically necessary section
Self-expanding absorptive sinus ostial dilation devices (and similar technologies) for evaluation or treatment of sinusitis and other sinonasal conditions due to insufficient evidence of efficacy

• OMC (ostiomeatal complex): The anatomical region evaluated on imaging for CRS severity.

• 510(k): FDA premarket notification demonstrating substantial equivalence to a legally marketed device.

Intranasal corticosteroids (and/or oral corticosteroids when appropriate)

Nasal lavage/irrigation if appropriate

Documentation Required

CT documentation

Provide recent CT images (considered recent if performed within 12 months) obtained after completion of medical management. CT documentation must identify which sinus(es) have disease and extent of disease using percent opacification or a scale such as the Modified Lund‑Mackay score. CT findings should include one or more of: bony thickening or remodeling, opacified sinus, ostial (outflow tract) obstruction, and mucosal thickening; sinonasal symptoms should be on the same side as CT findings.

CT performed within 12 months of planned procedure
Percent opacification or Modified Lund‑Mackay score to quantify extent
CT findings: bony thickening/remodeling, opacified sinus, ostial obstruction, mucosal thickening
Symptoms on same side as CT findings

Documentation Required

State-specific policy application

This Medical Policy does not apply to certain states; verify state‑specific policy versions prior to relying on this document. Specifically, Nebraska has a separate state‑specific policy; refer to that Nebraska policy for applicability in that state.

Policy does not apply to Nebraska — refer to Nebraska-specific policy
Verify other state-specific policy versions as listed in the Application section

Documentation Required

Use of evidence and tools

Benefit coverage is governed by federal, state, or contractual requirements and applicable laws; in the event of conflict, those requirements govern. UnitedHealthcare may use third‑party tools (for example, InterQual) to assist in benefit administration and coverage determinations.

Federal, state, or contractual requirements govern coverage decisions
UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist administration

FDA premarket notification demonstrating substantial equivalence to a legally marketed device

OMC device mean diameter (study)Mean diameter 4.8 ± 0.5 mm (self‑expanding absorptive device study)