Sinus Surgeries and Interventions (for Kansas Only)
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Defines medical necessity and coverage criteria for balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and related sinus interventions for UnitedHealthcare Community Plan members in Kansas.
Medical records documentation language was added clarifying that documentation may be required to assess whether the member meets clinical criteria, and describing what documentation must be present to support medical necessity.
Definition of 'Acute Bacterial Rhinosinusitis' was added.
An unspecified prior definition was removed (document notes removal without naming term).
Medical records documentation language was added to indicate that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess clinical criteria.
Definition for 'Acute Bacterial Rhinosinusitis' was added.
An unspecified definition was removed (text: 'Removed definition of:').
Several definitions were updated including Acute Rhinosinusitis, Chronic Rhinosinusitis, Functional Endoscopic Sinus Surgery, Modified Lund-Mackay Scoring System, and Recurrent Acute Rhinosinusitis.
Draft Classification System for Endoscopic Frontal Sinus Drainage and Rhinitis Medicamentosa (RM) were added to the summary of changes.
Description of Services, Clinical Evidence, and References sections were updated and the previous policy version CS138KS.02 was archived.
Coverage Criteria for Sinus Procedures
Members 18 Years of Age and Older — Coverage Criteria
Covered when ALL of the following are met:
Medical management must be documented; refer to InterQual CP: Procedures for full criteria.
Sinonasal symptoms should be present on the same side as CT findings.
FESS for ethmoid, frontal, and maxillary sinuses follows the general CRS criteria above.
Members Under 18 Years of Age — Coverage Criteria
Covered when ALL of the following pediatric-specific criteria are met:
For balloon dilation in children, dilation is limited to frontal, maxillary, or sphenoid sinuses.
Sinonasal symptoms must be present on the same side as CT findings.
Not Medically Necessary / Investigational
Interventions considered unproven or not medically necessary:
Although some devices are FDA-cleared, evidence is insufficient to support coverage.
Appropriate use of balloon sinus ostial dilation
Covered when ALL of the following are met (guideline-based consensus statements):
Derived from AAO-HNS, ARS, and society statements.
Not appropriate
These statements reached consensus in AAO-HNS guidance.
Balloon sinus ostial dilation (BSD) — covered with criteria
BSD may be considered when ALL of the following are met:
Supported by ARS, AAO-HNS, AAAAI/ACAAI/JCAAI, EUFOREA and NICE for selected patients.
Functional endoscopic sinus surgery (ESS) — covered with criteria
ESS is supported when ALL of the following are met:
Based on AAO-HNS recommendations and randomized trial evidence showing ESS improves SNOT-22 versus medical therapy.
BSD — exclusionary conditions
BSD is NOT appropriate when ANY of the following are present:
AAO-HNS recommends complete exposure/removal in these conditions rather than relying solely on balloon dilation.
Balloon sinus ostial dilation (BSD) and Functional Endoscopic Sinus Surgery (FESS) are subject to specific exclusionary rules. BSD is explicitly not covered for treatment of sinonasal polyps or tumors, and for cases of CRS or RARS that do not meet the policy’s stated clinical criteria. Self-expanding absorptive sinus ostial dilation devices (e.g., the SinuSys Vent‑OS system and similar devices) are considered unproven and not medically necessary because current evidence is insufficient to demonstrate safety and efficacy.
FESS is also not considered appropriate when the case does not meet the documented coverage criteria for CRS or RARS; conversely, FESS remains a proven and medically necessary option for indicated sinuses and specific conditions when the policy criteria are met.
Balloon sinus ostial dilation should not be used for clinical presentations that lack objective support. The AAO‑HNS consensus and this policy state BSD is not appropriate in patients who do not have both sinonasal symptoms and positive CT findings. Use of BSD for isolated headache or sleep apnea in the absence of CRS/RARS diagnostic criteria is specifically listed as inappropriate.
Before BSD is performed, CT scanning of the sinuses is required, and balloon dilation is not appropriate for patients who have sinonasal symptoms with a CT that does not show evidence of sinonasal disease. Lack of objective imaging or endoscopic evidence supporting the diagnosis may render the procedure not medically necessary.
When significant anatomic or pathologic disease is present—specifically sinus polyps, osteitis, bony erosion, or fungal disease—the policy follows guideline recommendations that the surgeon should perform an operation providing complete exposure of the sinus lumen and removal of diseased tissue. In these situations, relying solely on balloon or limited manual ostial dilation is not appropriate; FESS with adequate exposure and tissue removal is indicated.
The AAAAI/ACAAI/JCAAI and AAO‑HNS guidance underpin this recommendation by emphasizing that conditions requiring removal of inflamed bony partitions or extensive disease are not amenable to ostial dilation alone.
Most uncomplicated acute and subacute rhinosinusitis cases are diagnosed clinically and generally do not require imaging. CT of the sinuses without contrast is the preferred imaging method when imaging is indicated—for RARS, CRS, or preoperative planning—but routine imaging is not necessary for uncomplicated acute/subacute presentations.
Coverage determinations under this policy are subject to federal, state, or contractual requirements and applicable laws. Medical records documentation may be requested to assess whether the member meets the clinical criteria, but providing records does not guarantee coverage. Records must include relevant history, physical examination, and results of pertinent diagnostic tests or procedures; documentation should be legible, maintained in the medical record, and made available upon request.
Use of self‑expanding absorptive devices for sinus ostial dilation is considered investigational and not covered. The policy notes these devices (described as inserting an absorptive implant that expands in the ostium) have limited published evidence—small studies without comparison groups—and therefore their efficacy and safety remain unproven.
Other nonconforming or nonstandard uses of balloon dilation or ostial devices that fall outside the policy’s defined criteria are likewise treated as unproven or not medically necessary.
Balloon sinus ostial dilation (BSD) is appropriate only when both sinus‑related symptoms and objective imaging/endoscopic evidence of disease are present. The policy requires CT imaging of the sinuses prior to BSD and documentation of disease in the sinus targeted for dilation (e.g., ostial obstruction and mucosal thickening). BSD performed without both symptomatic presentation and positive CT findings is considered not appropriate and therefore not medically necessary.
Clinical selection criteria derived from society guidelines emphasize that BSD is best suited for milder, localized disease or selected cases of RARS when objective CT evidence of ostial occlusion and mucosal thickening is documented.
Balloon dilation should not be used as an alternative to FESS when the disease extent or pathology requires more extensive surgical management. For patients with more extensive disease—including but not limited to polyposis, osteitis, bony erosion, or fungal infection—traditional FESS with appropriate exposure and tissue removal is preferred because BSD alone would not address the full disease process and long‑term resolution versus FESS is unproven in this population.
Society statements indicate uncertainty about using BSD in place of FESS for extensive disease and recommend selecting the surgical approach according to disease severity and the need for definitive tissue removal.
The policy specifically states that the use of self‑expanding absorptive sinus ostial dilation devices is unsupported by sufficient evidence. Existing studies are limited by small sample sizes and lack of control groups, and therefore these devices are considered investigational until more robust comparative data are available.
Coding and Imaging Requirements
| 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. |
Provider Actions, Documentation & Prior Authorization
Prior authorization expected for listed CPTs
Coverage determinations for the listed sinus procedure CPT codes require documentation that clinical criteria are met; CT imaging and documentation of prior medical management are required to establish medical necessity.
Preprocedure imaging and objective confirmation required
CT scanning of the sinuses is required prior to balloon dilation; objective evidence of disease by nasal endoscopy or CT must support the diagnosis of CRS or RARS for procedures to be considered.
- CT images should be obtained after completion of medical management and document which sinuses and extent of disease (e.g., percent opacification or Modified Lund‑Mackay).
- Endoscopy documenting sinonasal abnormality or CT showing mucosal thickening/ostial occlusion are acceptable objective findings.
Preauthorization must document duration, prior therapy, and objective findings
Prior authorization for sinus surgery should include documentation of symptom duration, prior medical therapy trials, and objective findings (endoscopy or CT) to support candidacy.
- Document disease duration (e.g., ≥12 weeks for CRS) and at least two cardinal symptoms when applicable.
- Include CT with fine‑cut protocol for surgical planning and documentation of inflammation by endoscopy or imaging.
Medical record review may be required for coverage assessment
Medical records may be requested and reviewed to determine whether the member meets clinical criteria for coverage; presence of complete, legible documentation that supports medical necessity is required.
- Records must include relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures.
- Documentation should be legible, maintained in the record, and made available upon request.
Check InterQual and applicable plan requirements
Verify federal, state, and contractual benefit requirements before using this policy; InterQual is used for primary medical/surgical criteria when applicable.
- In the event of a conflict, federal, state, or contractual requirements govern coverage.
- InterQual is the primary criteria source used by UnitedHealthcare for medical/surgical decisions.
Required prior medical treatments must be documented
Conservative medical management must be tried and documented prior to FESS or balloon ostial dilation for CRS.
- Include trials of intranasal corticosteroids (and/or oral corticosteroids when appropriate).
- Document antibiotic therapy if bacterial infection was suspected and use of nasal lavage/irrigation when appropriate.
Surgery considered for recurrent episodes / CT‑confirmed cases
Surgery, including BSD, may be considered for recurrent acute rhinosinusitis when the patient has four or more annual episodes (with at least one episode confirmed by CT or endoscopy) and has failed appropriate medical therapy or experienced productivity loss.
- At least one episode should be confirmed by CT or nasal endoscopy.
- Failure of a trial of topical nasal steroids or other appropriate medical therapy should be documented.
Document prior medical therapy (steroids, saline, antibiotics) before surgery
Clinical trials and guidelines reference prior use of appropriate medical treatments before recommending ESS; documentation of prior medical management and its failure is expected.
- Prior treatments commonly include intranasal corticosteroids and saline nasal irrigations; selective antibiotics or systemic steroids as clinically indicated.
- Document that medical therapy was tailored and failed before proceeding to surgery.
Medical therapy should be tailored; require failed therapy and imaging per guidelines
Guidelines expect medical therapy to be individualized and typically require documentation of failed medical therapy before considering FESS; some guidelines recommend obtaining imaging after optimal medical therapy.
- Surgeon should avoid mandating a predefined medical regimen but document trials and response.
- Obtain fine‑cut CT without contrast for surgical planning when indicated.
Step therapy: none specified
No step therapy requirements are specified in this policy excerpt.
- Providers should still document prior medical management as described elsewhere in the policy.
Required documentation: history, exam, and diagnostic results
The patient's medical record must include relevant history, physical examination findings, and diagnostic test results (e.g., CT, endoscopy) that fully support the medical necessity of the requested services.
- Include documentation of symptom history, prior treatments and responses, and results of objective testing.
- Ensure records are legible and available upon request.
Require clinical and objective documentation (endoscopy/CT) for diagnosis
A clinical diagnosis of CRS or RARS should be based on sinusitis symptoms and supported by objective findings from nasal endoscopy or CT demonstrating sinonasal abnormality or mucosal thickening.
- Endoscopy findings or CT evidence of mucosal thickening/ostial occlusion satisfy objective documentation.
- Document that sinonasal symptoms correspond to the side(s) with objective findings.
Required diagnostic documentation: endoscopy or CT evidence
Document objective diagnostic evidence of CRS or RARS with nasal endoscopy showing sinonasal abnormalities or CT evidence of mucosal thickening/ostial obstruction to support surgical necessity.
- For each sinus to be treated, document CT findings (percent opacification or Modified Lund‑Mackay score) when applicable.
- Endoscopic documentation of inflammation or purulence should be recorded when performed.
Document symptom duration (≥12 weeks) and evidence of inflammation
Document disease duration consistent with CRS—symptoms persisting 12 weeks or longer with at least two cardinal symptoms—and document inflammation by endoscopy or CT when applicable.
- Record symptom onset and duration clearly in the medical record.
- List at least two cardinal symptoms (e.g., nasal drainage, obstruction, facial pain/pressure, diminished smell) and correlate with objective findings.
Medical records must include history, exam, and diagnostic tests
Medical records must include the relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; documentation should be legible and made available upon request to support medical necessity.
- Include prior treatment details, imaging reports, endoscopy findings, and clinician rationale for surgery.
- Maintain legible records and ensure they can be provided for review.
Records must support medical necessity and be legible/available
The patient's medical record must fully support medical necessity for requested services; documentation must be maintained, legible, and available on request.
- Ensure documentation ties symptoms, objective findings, and prior therapies to the requested procedure.
- Make records accessible for review during authorization or claims processing.
Insufficient documentation may lead to denial
Lack of adequate medical record documentation that fully supports medical necessity may result in denial of requested services.
- Missing history, exam findings, prior treatment documentation, or diagnostic test results can trigger denial.
- Legibility and availability of records upon request are required.
BSD requires both symptoms and CT confirmation
Balloon dilation is not appropriate for patients without sinonasal symptoms or without positive CT findings; CT scanning of the sinuses is a requirement before considering BSD.
- Patients with sinonasal symptoms but a CT that does not show evidence of sinonasal disease are not appropriate candidates for BSD.
- CT should be obtained after completion of medical management when planning BSD.
Denial risk if objective evidence or failed therapy not documented
Absence of objective evidence of inflammation (endoscopy or CT) or documentation of failed appropriate medical therapy may result in denial of coverage for surgical intervention.
- Lack of documentation verifying CRS diagnosis, endoscopic findings, or CT evidence of inflammation can trigger noncoverage.
- Document failure of appropriate medical therapy (tailored treatments) prior to surgery.
Incomplete medical records may result in noncoverage
Medical record insufficiency—such as missing history, exam, or diagnostic test results, illegible records, or inability to produce records on request—can result in services not being covered.
- Maintain complete, legible documentation of prior therapies, imaging, endoscopy, and clinician rationale.
- Make records available upon request to avoid coverage or payment denial.
Inadequate documentation increases risk of denial/noncoverage
Inadequate or missing documentation to support medical necessity may lead to denial or noncoverage of requested services.
- Ensure charts include history, exam, objective findings, prior treatment trials and outcomes, and operative planning details.
- Legible documentation that directly supports the requested procedure reduces denial risk.
Definitions and Terminology
Clinical Background and Evidence Summary
Rhinosinusitis encompasses acute, recurrent acute (RARS), and chronic forms (CRS). CRS is defined by symptoms lasting ≥12 weeks with at least two cardinal symptoms (for example, nasal drainage, obstruction, facial pain/pressure, or decreased smell) plus objective evidence of inflammation by nasal endoscopy or CT. Balloon sinus ostial dilation is described as a minimally invasive technique to dilate sinus ostia and may be used alone or with conventional FESS in selected patients; FESS remains the established surgical approach when full exposure and removal of diseased tissue are required.
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