UnitedHealthcare sinus surgery coverage update

Primary coverage criteria for Balloon OSTIAL dilation and FESS

Balloon sinus ostial dilation and/or FESS are proven and medically necessary when ALL of the following are met:

Duration: Symptoms lasted longer than 12 weeks>12 weeks

CRS defined as >12 weeks

Prior medical management: Persistence of symptoms despite recent medical management with full courses of: antibiotic therapy if bacterial infection suspected; intranasal corticosteroids (and/or oral corticosteroids when appropriate); and nasal lavage/irrigation if appropriatetrial of listed therapies

Required before surgery

Recent CT: CT images obtained after completion of medical management and a recent CT for each sinus to be treated within 12 monthsCT ≤12 months

CT must document disease and percent opacification

CT findings: CT confirmation of CRS in the sinus to be treated with one or more of: bony thickening; bony remodeling; or opacified sinus; documentation of which sinus and percent opacification requiredCT evidence of disease

Also requires sinonasal symptoms on same side as CT findings

Symptoms concordant with imaging: Sinonasal symptoms (pain, pressure, drainage) present on the same side as CT scan findings of rhinosinusitissymptom concordance

Ostial or mucosal findings: Ostial obstruction (outflow tract obstruction) and mucosal thickening in the sinus to be treated (for FESS: ostial obstruction; for ethmoid: mucosal thickening)CT/endoscopy evidence

For balloon dilation, dilation limited to frontal, maxillary, or sphenoid sinuses

Coverage criteria for RARS

Recurrent Acute Rhinosinusitis (RARS) coverage criteria:

Episode frequency: Four or more episodes per year with distinct symptom-free intervals between episodes≥4 episodes/year

Each episode should meet diagnostic criteria for acute bacterial rhinosinusitis

Symptom-image concordance: Sinonasal symptoms (pain, pressure, drainage) present on the same side as CT findingsconcordant

For balloon dilation, ostial obstruction and mucosal thickening required in sinus to be dilated

Confirmatory imaging: Recent CT evidence of disease obtained after completion of medical management for the sinus(es) to be treatedCT ≤12 months

Additional indications for FESS

FESS is also medically necessary when ANY of the following CT-confirmed conditions are present:

FESS-specific indications: Complications of sinusitis (e.g., abscess); symptomatic mucocele; symptomatic concha bullosa; polyposis with obstructive symptoms (see CRS-with-polyps criteria); or sinonasal tumorCT confirmation where applicable

Refer to CRS-with-polyps criteria for polyposis

Appropriate indications

Covered when ALL of the following are met

BSD coverage criteria: 1) Patient has symptoms consistent with CRS or RARS AND 2) Objective documentation of sinonasal inflammation by nasal endoscopy OR mucosal thickening on CT of the paranasal sinuses (non-contrast sinus CT preferred) AND 3) Failure of appropriate medical therapy for CRS or RARS prior to BSD (except where indicated by specialty statements for selected cases).

Based on AAO-HNS and ARS statements

Indications for ESS / surgical intervention

Coverage supported when clinical indications and prior therapy align with specialty society guidance

ESS Indications (adult): History consistent with AAO-HNS clinical indicators, including: allergic fungal rhinosinusitis; CRS with or without nasal polyps with persistent symptoms and objective endoscopic/CT evidence refractory to medical treatment; unilateral paranasal sinus opacification suspicious for fungus ball or benign neoplasm; sinonasal polyposis with airway obstruction or suboptimal asthma control; complications of sinusitis (e.g., orbital or skull base extension); mucocele; or RARS.

Based on AAO-HNS clinical indicators

Balloon dilation (XprESS) coverage

Coverage considerations for balloon dilation/XprESS

Balloon sinuplasty / XprESS candidacy: Eligible when patients have uncomplicated CRS (no severe nasal polyposis) and have failed appropriate medical therapy; XprESS may be considered as an alternative to FESS with similar outcomes and faster recovery in selected patients.

Supported by NICE guidance and EUFOREA position statements

Efficacy evidence

Evidence supporting efficacy of ESS

Expected outcomes following ESS: ESS is associated with statistically and clinically meaningful improvements in patient‑reported outcomes (pooled mean SNOT-22 change ~26.02), durable quality-of-life benefits in long-term follow-up, and evidence that greater extent of ESS can lead to improved symptom outcomes and reduced revision rates in some studies.

Findings from systematic reviews and meta-analyses

Criteria for coverage of sinus surgery (ESS and balloon procedures)

Covered when ALL of the following are met (per referenced guideline indicators and consensus statements):

ESS indications: History of one or more specific indications (e.g., allergic fungal rhinosinusitis; CRS with or without nasal polyps with persistent symptoms and objective evidence by endoscopy and/or CT refractory to medical treatment; unilateral paranasal sinus opacification suspicious for fungus ball or neoplasm; sinonasal polyposis with obstruction or suboptimal asthma control; complications of sinusitis; mucocele; RARS).

AAO-HNS clinical indicators and specialty society guidance

Prior medical therapy: Failed appropriate medical management, which includes topical intranasal corticosteroids and nasal irrigations; some guidelines recommend additional systemic antibiotics or prolonged low‑dose antiinflammatory antibiotics as part of the trial for at least eight weeks in certain recommendations.

EUFOREA and specialty statements

Objective documentation: Objective disease demonstrated by CT and/or nasal endoscopy and, when available, symptom severity measures such as SNOT-22 ≥20 to support decision for surgery.

Unproven interventions

Experimental / insufficient evidence:

Self-expanding absorptive sinus ostial dilation devices: Use of self-expanding absorptive sinus ostial dilation devices is considered experimental/insufficient due to limited studies lacking comparison groups and small sample sizes.

Evidence limited by study design and sample size

Balloon sinus ostial dilation (balloon sinuplasty) is considered not medically necessary when the patient does not meet the policy’s required clinical criteria. Specifically, BSD is unproven and not covered for cases of CRS or RARS that fail to meet the documented criteria (including symptom duration, objective imaging/endoscopic confirmation, and prior medical management), and for patients with sinonasal polyps or tumors. Providers should document the required symptoms, completion of appropriate medical therapy, and objective CT or endoscopic evidence before BSD will be considered.

Self-expanding absorptive sinus ostial dilation devices are considered experimental/insufficient evidence and not medically necessary. The available studies are limited by small sample sizes and lack of comparison groups, and do not provide adequate evidence to support routine use for evaluating or treating sinusitis or other indications.

Balloon dilation should not be performed in patients who lack both sinonasal symptoms and concordant positive CT findings. AAO‑HNS guidance states that BSD is inappropriate for patients without concurrent symptoms and CT evidence of disease, and CT scanning is required before balloon dilation can be performed.

NICE guidance supports use of the XprESS multi‑sinus dilation system in selected patients with uncomplicated CRS but explicitly recommends that XprESS not be used in patients with severe nasal polyposis. XprESS may be considered an alternative to FESS in patients without severe polyposis.

Device regulatory information is provided for context only: devices used for balloon catheter dilation fall under FDA product code LRC and manufacturers may have 510(k) clearances, but FDA clearance alone is informational and is not a basis for coverage decisions. Separately, FESS is a surgical procedure and is not subject to FDA device regulation.

Functional Endoscopic Sinus Surgery (FESS) is not medically necessary when the patient’s CRS or RARS presentation does not meet the policy’s required criteria. The policy specifies that FESS is indicated only when clinical criteria are met (including adequate trial of medical therapy and objective confirmation by CT or endoscopy); FESS for cases that do not meet these criteria is considered unproven and not supported.

Balloon sinus ostial dilation has not been shown to be effective for barometric pressure–related sinus headache when there is no mucosal thickening on CT. A randomized trial that enrolled patients with sinus pressure headache without CT evidence of mucosal thickening found no difference between active BSD and placebo nasal dilation, supporting that BSD is not effective for this indication in the absence of objective CT findings.

Imaging is not routinely indicated for uncomplicated acute or subacute rhinosinusitis and most cases are diagnosed clinically. However, a non‑contrast sinus CT is indicated when endoscopic sinus surgery is being considered or planned, and for evaluation of RARS or objective confirmation in chronic or recurrent cases; CT provides the anatomic detail required for surgical planning.

The evidence for self‑expanding absorptive sinus ostial dilation devices is insufficient to support their use. Existing literature is limited by lack of control/comparison groups and small sample sizes, and therefore these devices are considered unproven.

Codes and coding-related criteria

Prior Authorization

Prior authorization and documentation requirements

Prior authorization is required for endoscopic sinus surgery (ESS) and related sinus procedures. Providers must obtain prior authorization and document objective confirmation of disease and failure of appropriate medical management before scheduled surgery.

Prior authorization required for ESS and sinus procedures (see applicable CPT codes below).
Medical records must document objective confirmation (CT or nasal endoscopy) and failed medical therapy.
Failure of medical therapy must be documented prior to authorization: see Medical management trial requirements below.

Documentation Required

Imaging requirements and timing

Providers must submit recent imaging and medical records to support clinical criteria for ESS. A non-contrast CT of the paranasal sinuses is the preferred imaging modality for preoperative planning and is required to demonstrate sinus inflammation and provide anatomic detail for surgical planning.

A CT scan is considered recent if performed within 12 months of the planned procedure.
CT provides necessary anatomic detail (ostiomeatal unit, ethmoid anatomy, anatomic variants) for surgical planning and to assess risk.
CT evidence of disease is required (EUFOREA) and sinus inflammation on CT is part of objective confirmation (ICAR-RS).

Prior Authorization

Medical management trial before surgery

Providers must document that the member has undergone an adequate trial of appropriate medical management prior to ESS. Documentation in the medical record should include details of therapies attempted, duration, response, and objective symptom scores or endoscopic findings when available.

Required medical management prior to surgery: at minimum a trial of topical intranasal corticosteroids for an adequate duration.
EUFOREA recommends a minimum 8-week trial of topical intranasal corticosteroid plus either a short-course broad-spectrum or culture-directed systemic antibiotic or a prolonged low-dose systemic anti-inflammatory antibiotic.
ICAR-RS and AAO-HNS guidance: document failure of maximal medical therapy (MMT) including saline irrigation and topical intranasal corticosteroids; include details of systemic antibiotic use, oral corticosteroid trials if used, and response to therapy.
Preoperative SNOT-22 and nasal endoscopy findings (when available) should be included in the record to verify criteria.

Documentation Required

Medical records and objective confirmation

Clinical documentation required to verify criteria for prior authorization and coverage determinations must be submitted with the request. This includes objective confirmation of disease and evidence of failed medical therapy.

Recent CT scan images/reports (within 12 months) demonstrating sinus inflammation and anatomic detail for surgical planning.
Documentation of symptoms consistent with CRS/RARS for the required duration (e.g., 12 weeks for CRS) and cardinal symptoms per ICAR-RS.
Records of medical therapy trials: dates, medications (topical intranasal corticosteroids, systemic antibiotics, oral corticosteroids, saline irrigation), durations, and clinical response.
Preoperative SNOT-22 score (recommended threshold ≥20) when available, and Lund-Mackay CT score (recommended minimum ≥1).
Nasal endoscopy findings including evidence of mucosal inflammation or purulence, if performed.

Covered CPT CodesCPTCovered

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

Device/Product Codesmixed

LRC	FDA product code for ENT manual surgical instruments (includes dilation devices); 510(k)-exempt category

Provider requirements, documentation, and prior authorization

Prior Authorization

Require objective confirmation and failed medical therapy

Prior authorization requests should include both clinical symptoms and objective confirmation (nasal endoscopy or CT) plus documentation that appropriate medical therapy was tried and failed before approving BSD for CRS or RARS.

Objective confirmation via nasal endoscopy or non-contrast sinus CT is required.
Record of failed appropriate medical management (see required therapies) must be provided.

Prior Authorization

Prior authorization must show objective disease and failed medical therapy for ESS

Prior authorization for ESS and other sinus procedures must demonstrate objective disease by endoscopy and/or CT and document failure of appropriate medical therapy before authorization is granted.

CT imaging should generally be obtained after optimal medical therapy when ESS is considered.
Provide endoscopy or CT findings showing sinonasal inflammation concordant with symptoms.

Prior Authorization

Include documentation of failed medical management in prior authorization

Prior authorization submissions should include specific documentation of failed medical management such as trials of topical intranasal corticosteroids and nasal irrigation, and antibiotics when bacterial infection is suspected.

Document full courses of antibiotic therapy if bacterial infection suspected.
Document use of intranasal corticosteroids (and oral corticosteroids when appropriate).
Document nasal lavage/irrigation and duration of these therapies.

Step Therapy

Document required medical management trial before surgery

Providers must document a trial and persistence of medical management prior to surgery, including antibiotics when bacterial infection is suspected, intranasal corticosteroids (± oral corticosteroids when appropriate), and nasal lavage/irrigation.

Record treatment durations and response to each therapy.
Show that CT images were obtained after completion of medical management.

Step Therapy

Attempt appropriate medical management (saline, INS, antibiotics as indicated)

Appropriate medical management should be attempted prior to surgical interventions including BSD; recommended therapies include saline irrigation and topical intranasal corticosteroids, with antibiotics as indicated.

Saline nasal irrigation and topical intranasal corticosteroids are recommended for symptom relief.
Antibiotics for suspected bacterial CRS per clinical judgment; longer durations may be appropriate.

Step Therapy

Document prior use of topical INS, saline irrigation, and other medical therapies

Medical therapies commonly recommended prior to surgical consideration include topical intranasal corticosteroids, saline irrigation, intranasal antihistamines, and decongestants; these should be documented in the medical record.

List specific agents used, doses, start/stop dates, and patient response.
Include adjunctive therapies when applicable (intranasal antihistamines, decongestants).

Step Therapy

Follow guideline-recommended medical therapy trial (e.g., ≥8 weeks INS ± antibiotic) before surgery

Guidelines (EUFOREA and others) recommend a trial of medical therapy before offering ESS or balloon interventions, e.g., at least eight weeks of topical intranasal corticosteroid plus either a short-course systemic antibiotic or prolonged low‑dose antiinflammatory antibiotic in some recommendations.

EUFOREA recommends ≥8 weeks of topical INS plus adjunctive systemic antibiotic strategies and considers SNOT-22 and CT Lund-Mackay thresholds.
Document duration and type of antibiotic therapy when used.

Documentation Required

Expect requests for medical records to verify clinical criteria

Medical records may be requested to verify that the member meets clinical criteria, including documentation of symptom duration, prior medical therapy, and recent CT imaging within 12 months of the planned procedure.

Ensure records include dates and specifics of prior treatments and imaging.
Attach copies of CT reports/images and endoscopy notes when available.

Documentation Required

Document symptoms, endoscopy/CT findings, and failed therapies for BSD claims

Clinical documentation should include sinonasal symptoms, objective confirmation of sinonasal inflammation via nasal endoscopy or non‑contrast sinus CT (preferred for preoperative evaluation), and documentation of failed appropriate medical therapy when claiming BSD for CRS or RARS.

Include symptom concordance with imaging (same side as CT findings).
Provide endoscopy findings or CT descriptions showing mucosal thickening, ostial obstruction, or opacification.

Documentation Required

Include endoscopy/CT and records of prior optimal medical therapy for ESS

Required clinical documentation for ESS should include objective evidence of disease by endoscopy and/or CT imaging and records of prior optimal medical therapy (e.g., topical intranasal corticosteroids and nasal irrigations).

Provide CT imaging obtained after optimal medical therapy when ESS is planned.
Attach prior treatment records demonstrating inadequate response to medical management.

Documentation Required

Provide objective endoscopy/CT and consider SNOT-22 documentation (≥20 recommended by some)

Objective disease documentation should include endoscopy and/or CT evidence of sinus inflammation and, when available, symptom severity measures such as a preoperative SNOT-22 score (some guidelines recommend SNOT-22 ≥20) to support refractory disease and eligibility for ESS.

Provide SNOT-22 score if available; note that some guideline bodies recommend ≥20 as a threshold.
Include CT findings and Lund-Mackay scoring where applicable.

Denial Risk

Denial risk if documentation of symptoms, imaging, and prior therapy is missing

Lack of required medical records documentation may lead to denial because benefit coverage is determined by the member-specific plan and documentation may be required to assess clinical criteria.

Failure to submit CT reports, endoscopy findings, or treatment records can result in requests for additional information or denial.

Denial Risk

Risk of denial for BSD performed without objective CT evidence and documented prior therapy

Performing balloon dilation without objective evidence of sinonasal disease on CT or without documentation of sinonasal symptoms and appropriate prior medical therapy may lead to denial; CT scanning is required prior to BSD.

Balloon dilation is not appropriate for patients without both sinonasal symptoms and positive CT findings.
CT scan must be obtained prior to performing BSD.

Denial Risk

Lack of post‑MMT CT may jeopardize support for ESS

If CT imaging is not obtained after optimal medical therapy when ESS is being considered, there may be insufficient objective documentation to support surgery and this can lead to lack of support or requests for additional records.

Obtain CT of the paranasal sinuses after completion of medical therapy when planning ESS.

Note

Obtain non‑contrast sinus CT for surgical planning; imaging gaps may trigger additional requests

CT of the paranasal sinuses without contrast is the imaging method of choice to define sinus anatomy when ESS is considered or planned; absence of appropriate imaging for surgical planning may prompt requests for imaging or additional documentation.

For suspected sinonasal mass or complications, provide MRI/CT as complementary studies when indicated.
Include CT images/reports that define ostiomeatal anatomy and anatomic variations relevant to surgery.

Key definitions and terms

Chronic Rhinosinusitis (CRS) definition

DefinitionInflammation of the paranasal sinuses persisting >12 weeks with >=2 symptoms (nasal obstruction, mucopurulent drainage, facial pain/pressure/fullness, or decreased sense of smell) and objective evidence of inflammation (polyps, edema, purulent mucus, or radiographic imaging)

Symptom durationMinimum symptom duration: >12 weeks

Objective confirmationDiagnosis requires documentation of inflammation by endoscopy (polyps, purulence, edema) or radiographic imaging

Recent Computed Tomography (CT) Scan definition

DefinitionA CT scan performed within 12 months of the planned procedure is considered recent

Preferred modalityNon-contrast sinus CT is the imaging method of choice for evaluation when ESS or BSD is considered

RoleUsed to document disease, anatomy for surgical planning, and percent opacification per sinus

Recurrent Acute Rhinosinusitis (RARS) definition

DefinitionFour or more episodes per year of acute bacterial rhinosinusitis (ABRS) with distinct symptom-free intervals between episodes

Episode criteriaEach episode should meet diagnostic criteria for ABRS (symptom duration/worsening or confirmed bacterial episode when possible)

ConfirmationWhen ABRS is not lab-confirmed, examination during an episode or CT/endoscopy evidence for at least one episode is preferred to substantiate diagnosis

Modified Lund-Mackay Scoring System

DefinitionCT-based scoring system assigning 0–5 per sinus based on percent opacification (0=0%, 1=1–25%, 2=26–50%, 3=51–75%, 4=76–99%, 5=100%); ostiomeatal complex scored 0–2; total score per side summed to maximum 54

PurposeQuantifies severity of sinus opacification on CT to support objective evidence of disease

Use in policyReferenced as the metric (CT Lund-Mackay) with a suggested minimum score >=1 for surgical consideration per EUFOREA

Functional Endoscopic Sinus Surgery (FESS)

DefinitionMinimally invasive, mucosal-sparing endoscopic surgical technique to open and drain sinus air cells and ostia for medically refractory CRS with or without polyps or RARS

IndicationsUsed for CRS refractory to medical therapy, allergic fungal rhinosinusitis, RARS, mucocele, sinonasal polyposis with obstruction, complications of sinusitis, and selected neoplasms

Procedure noteExtent of procedure ranges from limited to more extensive approaches (e.g., Draf classifications for frontal sinus) depending on disease and anatomy

RARS (AAO-HNS definition)

AAO-HNS RARS statementRARS defined per AAO-HNS as recurrent episodes of acute bacterial rhinosinusitis supported by symptoms and objective CT or endoscopic findings; BSD may have a role when ostial occlusion and mucosal thickening are present

Episode threshold>=4 episodes per year with symptom-free intervals

Diagnostic supportAt least one episode confirmed by CT or endoscopy is recommended to substantiate diagnosis when ABRS not laboratory-confirmed

ESS / FESS definition

DefinitionEndoscopic surgical approaches to the paranasal sinuses used to treat CRS, nasal polyposis, mucoceles, and selected neoplasms; extent ranges from limited to radical procedures with differing outcomes

GuidanceImaging (CT) is generally obtained after optimal medical therapy when ESS is being considered; indications follow AAO-HNS clinical indicators

Relation to FESSFESS is a form of ESS characterized by mucosal-sparing endoscopic techniques for medically refractory disease

XprESS / balloon sinuplasty definition

DefinitionMinimally invasive sinus dilation systems (eg, XprESS) intended to dilate sinus ostia to restore drainage in selected patients with uncomplicated CRS

Patient selectionRecommended for patients with uncomplicated CRS who do not have severe nasal polyposis and who have failed appropriate medical therapy

BenefitsMay have similar clinical outcomes to FESS in selected patients with faster recovery and more frequent local anesthesia use (per NICE)

Endoscopic Sinus Surgery (ESS)

DefinitionSurgical management for CRS guided by endoscopic visualization; indicated for allergic fungal rhinosinusitis, CRS refractory to medical therapy with objective disease on endoscopy/CT, unilateral opacification suspicious for neoplasm or fungus ball, sinonasal polyposis with obstruction or asthma impact, complications, mucocele, and RARS

Imaging roleCT of the paranasal sinuses without contrast is indicated to define anatomy when ESS is considered or planned

Procedure extentExtent ranges from limited to extensive (eg, Draf procedures) determined by underlying pathology and anatomy

Balloon sinuplasty / ostial dilation definition and device classification

DefinitionCatheter-based dilation of sinus ostia (balloon sinuplasty/ostial dilation) intended to restore sinus drainage

Device classificationDevices fall under FDA product code LRC (instrument; ENT, manual surgical); product code LRC is 510(k)-exempt though manufacturers may voluntarily submit 510(k) information

Regulatory noteFDA 510(k) clearance has been granted for some systems (eg, SinuSys Vent-OS) but FDA clearance alone is informational and not a basis for coverage decisions

Chronic rhinosinusitis (CRS) is inflammation of the paranasal sinuses lasting longer than 12 weeks and may present with symptoms such as nasal obstruction, mucopurulent drainage, facial pain/pressure, or decreased sense of smell. Balloon sinuplasty is a catheter‑based approach intended to restore ostial drainage and may be used in selected patients, while FESS is a minimally invasive, mucosal‑sparing surgical technique indicated for medically refractory CRS and other CT‑confirmed conditions (eg, mucocele, sinonasal tumor, complicated sinusitis). Recent CT imaging and documentation of prior medical therapy are required to confirm indications for surgery.

OpenPayer

Sinus Surgeries and Interventions

Coverage criteria for sinus procedures

Codes and coding-related criteria

Provider requirements, documentation, and prior authorization

Key definitions and terms

Clinical and evidence background

Policy revision history and related policies