Sinus Surgeries and Interventions (for Kentucky Only)
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Medical policy governing coverage and medical necessity criteria for balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and self‑expanding absorptive sinus ostial dilation for UnitedHealthcare Community Plan members in Kentucky.
Medical Records Documentation Used for Reviews: added language clarifying that medical records documentation may be required to assess whether the member meets the clinical criteria for coverage and specifying documentation expectations.
Medical Records Documentation Used for Reviews language was added describing required documentation to support medical necessity.
Definition of 'Acute Bacterial Rhinosinusitis' was added.
Definitions for Draf Classification System for Endoscopic Frontal Sinus Drainage and Rhinitis Medicamentosa were removed.
Definitions of Acute Rhinosinusitis, Chronic Rhinosinusitis, Functional Endoscopic Sinus Surgery, Modified Lund-Mackay Scoring System, and Recurrent Acute Rhinosinusitis were updated.
Description of Services, Clinical Evidence, and References sections were updated to reflect current information and previous policy version CS138KY.12 was archived.
Coverage and Medical Necessity Criteria
inv-01: Balloon sinus ostial dilation — Adults (18+)
Covered when ALL of the following are met:
Refer to InterQual for the specific clinical logic and required clinical parameters.
CT imaging is required per AAO-HNS prior to BSD; document which sinus has disease and extent of disease.
Surgeon may individualize therapy; records should show trials and inadequate response.
Not appropriate when sinonasal polyps, fungal disease, osteitis, or bony erosion require complete exposure and tissue removal rather than dilation alone.
inv-02: FESS — Adults (18+) general criteria
Covered when clinical and imaging criteria are met; medical therapy failure should be documented where applicable.
Medical therapy should be tailored; CT with fine-cut maxillofacial without contrast is recommended for surgical planning.
Sphenoid FESS is unproven for other conditions.
Do not base extent solely on arbitrary imaging thresholds; in cases with polyps/osteitis/fungal disease, surgical removal of diseased tissue is required rather than dilation alone.
inv-03: Pediatric (under 18) criteria
Covered when ALL pediatric-specific criteria are met:
Pediatric diagnosis should follow AAO-HNS pediatric CRS guidance.
Adenoidectomy should be strongly considered as a first-line surgical option when appropriate prior to ESS in children per AAO-HNS pediatric guidance.
For balloon dilation in children, dilation is limited to frontal, maxillary, or sphenoid sinuses only.
inv-04: Recurrent Acute Rhinosinusitis (RARS)
Covered when ALL of the following are met for RARS:
At least one episode should be confirmed by CT or nasal endoscopy when possible.
AAO-HNS and Saltagi systematic review recommend objective confirmation for surgical consideration in RARS.
Recommendations from systematic reviews and guidelines support considering surgery when medical therapy fails or productivity loss occurs.
inv-05: Coverage criteria for BSD
Coverage for balloon sinus dilation (BSD) is met when ALL of the following are documented:
AAO-HNS and ARS emphasize objective confirmation prior to BSD.
ARS and AAO-HNS guidance support BSD after failure of medically appropriate therapy.
NICE supports XprESS for uncomplicated CRS without severe nasal polyposis; BSD should be reserved for selected patients.
inv-06: Covered when ALL of the following are met
Covered when ALL of the following guideline- and evidence-based elements are present:
AAO-HNS diagnostic criteria and ICAR-RS references apply.
AAO-HNS and allergy society guidance: do not mandate a fixed regimen but document trials when used to support surgical candidacy.
Evidence supports ESS effectiveness and that greater extent of surgery may improve outcomes in appropriate patients.
inv-07: Guideline-based coverage criteria
Guideline-based coverage requires documentation of clinical, imaging, and prior therapy elements:
ICAR-RS and AAO-HNS diagnostic statements apply.
Consider Lund-Mackay or modified scoring where appropriate (EUFOREA/ICAR-RS examples).
AAO-HNS recommends individualized medical therapy and documentation of trials when used to support surgery.
These thresholds are examples from EUFOREA/ICAR-RS and may be applied as part of comprehensive assessment.
inv-08: Surgical extent guidance
Surgical extent should be determined by disease phenotype and treatment goals; document rationale for the planned extent:
AAO-HNS recommends individualized decision-making about surgical extent.
Balloon or ostial dilation alone is insufficient in these scenarios per AAO-HNS.
Follow AAO-HNS recommendations to discuss expectations and postoperative care with the patient.
The policy considers self‑expanding absorptive sinus ostial dilation devices investigational. Available studies are limited (small sample sizes, lacking comparison groups), and current evidence is insufficient to conclude safety and efficacy for evaluating or treating sinusitis or other indications. Therefore use of these devices is unproven and not medically necessary pending stronger comparative data and demonstration of clinical benefit.
The policy explicitly states that balloon sinus ostial dilation (BSD) is not indicated for treatment of sinonasal polyps or tumors and is not appropriate for cases of CRS or RARS that do not meet the policy’s stated diagnostic and objective criteria. In addition, when disease features such as polyposis, osteitis, bony erosion, or fungal disease are present, the AAO‑HNS recommends complete exposure and removal of diseased tissue rather than relying on dilation alone.
Balloon ostial dilation should be considered only in patients who have both sinonasal symptoms and objective disease on CT or endoscopy. CT scanning of the sinuses is required prior to performing BSD, and candidacy generally requires documented failure of appropriate medical management (e.g., intranasal corticosteroids ± oral steroids when appropriate, antibiotics if infection suspected, and nasal saline irrigation). BSD is most appropriate for selected patients with limited disease (including some RARS and frontal sinusitis) and as an adjunct in select surgical settings; it is not a substitute for thorough surgical management when disease extent warrants.
The policy highlights scenarios where ostial dilation alone is insufficient. In patients with sinus polyps, osteitis, bony erosion, or fungal disease, surgical management should involve complete exposure of the sinus cavity and removal of diseased tissue (traditional FESS techniques) rather than balloon or manual ostial dilation alone.
For self‑expanding absorptive sinus ostial dilation devices the evidence base is inadequate to support coverage: published reports are small, often single‑arm or pilot in design, and lack comparative data demonstrating clinical effectiveness and safety. Given these limitations, use of these devices remains unproven and not medically necessary.
Coverage determinations under this policy are subject to applicable federal, state, and contractual requirements. If plan‑specific terms or regulatory requirements conflict with this policy, those federal, state, or contractual provisions govern the member’s coverage.
Procedures and device uses not meeting the stated clinical and objective criteria— including self‑expanding absorptive devices and BSD applied to excluded presentations—are considered unproven and not medically necessary. Providers should document how a requested intervention satisfies the policy’s required clinical findings and prior therapy; absence of such documentation may lead to noncoverage.
Randomized evidence does not support BSD as an effective treatment for barometric pressure–related sinus headache when CT shows no mucosal disease. A blinded RCT found no difference between active ostial dilation and a nasal placebo procedure in patients without mucosal thickening, and BSD should not be used for barometric headache in the absence of objective mucosal disease.
When considering BSD in place of FESS, exercise caution: guidelines and evidence note that balloon dilation may be reasonable for minor, localized disease but its use as an alternative to FESS is unproven for patients with more extensive or complex disease. Decisions should be individualized based on disease extent, phenotype, and expected need for tissue removal; FESS remains the appropriate approach when complete exposure and debridement are required.
Reiterating clinical decision‑making guidance: balloon or ostial dilation alone is not appropriate when sinonasal polyps, osteitis, bony erosion, or fungal disease are present—these conditions require surgical exposure and removal of diseased tissue rather than dilation alone.
Applicable Codes and Technical Criteria
| 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. |
| LRC | FDA product code for instrument, ENT, manual surgical (includes balloon catheter dilation devices) |
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization & coding: document criteria and codes
Prior authorization is implied for the sinus procedure CPT codes listed in the policy; providers should document clinical criteria and imaging to support medical necessity prior to authorization. Applicable CPT codes include balloon dilation and related endoscopic sinus surgery codes (e.g., 31295–31298 and listed endoscopy codes).
- Prior authorization is implied by policy application and documentation requirements for listed Applicable Codes.
- Document clinical criteria and relevant imaging (CT or endoscopy) when requesting authorization.
Document objective imaging/endoscopy and failed medical therapy before BSD
Before performing BSD, document objective evidence of disease via CT or nasal endoscopy and show failure of appropriate medical therapy; the attending surgeon retains final decision regarding use of techniques. CT images should be obtained after completion of medical management and document which sinus and extent of disease.
- Objective evidence: nasal endoscopy demonstrating sinonasal abnormality or CT showing mucosal thickening, ostial obstruction, bony remodeling, or opacified sinus.
- Document failure of appropriate medical therapy (see medical therapy callouts) prior to BSD.
- Surgeon discretion: final selection of techniques/instrumentation is the attending surgeon's responsibility.
Prior authorization: indicate BSD/XprESS is for selected patients after failed therapy
Prior authorization requests for BSD/XprESS must reflect that the patient is a selected candidate after failure of medically appropriate therapy and include objective evidence of inflammation; XprESS is supported for uncomplicated CRS without severe nasal polyposis per NICE guidance.
- Include documentation of failed medical therapy and nasal endoscopy or CT evidence when submitting prior authorization.
- For XprESS, ensure patient does not have severe nasal polyposis and document uncomplicated CRS status when applicable.
Medical records may be requested — provide complete, legible documentation
Medical records may be requested to assess whether the member meets clinical criteria; provide complete, legible documentation but note that supplying records does not guarantee coverage. Records must be made available upon request.
- Medical records used for review must fully support medical necessity and include relevant history, physical exam, and diagnostic test results.
- Making records available for review does not guarantee authorization or payment.
Use InterQual as primary criteria and verify plan/state-specific rules
UnitedHealthcare uses InterQual as the primary source for medical/surgical criteria; when InterQual criteria are used for decisions, also check plan- or state‑specific policies that may apply (federal/state/contractual requirements govern in conflicts).
- Confirm InterQual CP: Procedures, Balloon Ostial Dilation for specific clinical logic.
- If InterQual lacks applicable criteria, UnitedHealthcare may apply its own Medical Policies or Coverage Determination Guidelines as approved by state authority.
Document conservative medical therapy trials before surgical consideration
Document prior adequate medical management before surgery: intranasal corticosteroids (with or without a short course of oral corticosteroids when appropriate), nasal saline irrigation, and antibiotics when bacterial infection is suspected.
- Record trials of intranasal corticosteroids and nasal irrigation.
- If bacterial infection suspected, document antibiotic therapy; oral corticosteroids when clinically appropriate.
Surgery (including BSD) considered after failed medical therapy; RARS specific criteria
Consider surgery, including BSD, after failure of medical therapy; for RARS, consider surgery when there are four or more episodes per year with at least one CT or endoscopy‑confirmed episode and either failure of topical nasal steroids or RARS-related productivity loss.
- Document number of RARS episodes and confirm at least one episode by CT or endoscopy.
- Document failure of topical nasal steroids or evidence of productivity loss to support surgical consideration.
Document prior medical therapy trials and rationale per guideline guidance
Document prior medical therapy such as intranasal corticosteroids and saline irrigation; tailor therapy per AAO‑HNS guidance and record trials and reasons for failure when used to support surgical candidacy.
- Record specific medical therapies tried (topical nasal steroids, saline irrigations) and duration.
- AAO‑HNS advises tailored medical therapy rather than a mandated fixed regimen — document what was attempted and the clinical response.
List prior medical therapy trials and rationale for surgery in the record
Provide examples of prior medical therapy in the record and document rationale for proceeding to surgery when applicable, such as inadequate response to topical nasal steroids, saline irrigation, or appropriately used antibiotics/steroids.
- List specific trials (topical steroids, nasal irrigations, antibiotics when indicated) with dates and outcomes.
- Explain why surgery is being pursued (persistent symptoms, QOL impact, imaging correlation).
Additional provider action (reserved)
(Reserved for additional provider-action items pending source mapping.)
- No additional source-mapped actions available.
Required documentation: history, exam, diagnostic test results (CT within 12 months)
Required documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; a CT is considered recent if performed within 12 months.
- Include documentation of which sinuses are affected and imaging details (percentage opacification or Modified Lund‑Mackay score) when CT is used.
- Maintain legible records and make them available upon request.
Support clinical diagnosis with endoscopy or CT before dilation
Clinical diagnosis should be supported by nasal endoscopy or CT evidence of sinonasal abnormality or mucosal thickening prior to considering dilation; document failure of appropriate medical therapy for CRS or RARS.
- Nasal endoscopy findings or CT demonstrating mucosal thickening/ostial occlusion should be documented.
- Document specific prior medical treatments and their outcomes.
Document CRS diagnosis: duration, symptoms, and objective evidence
Document CRS diagnosis using duration (≥12 weeks), at least two cardinal symptoms, and objective evidence of sinonasal inflammation from rhinoscopy, endoscopy, or CT to verify candidacy for surgery.
- Record duration of symptoms (≥12 weeks) and list which cardinal symptoms are present.
- Include objective evidence: anterior rhinoscopy, nasal endoscopy, or CT findings.
Preoperative imaging: fine‑cut maxillofacial CT without contrast and surgical planning details
For surgical planning, obtain and document a fine‑cut maxillofacial CT without contrast per ACR guidance and describe disease characteristics, prior therapies, and counseling about expected outcomes and postoperative care.
- CT imaging should be a fine‑cut maxillofacial CT without contrast for preoperative evaluation.
- Document disease extent, prior medical/surgical therapy, and patient counseling regarding expectations and postoperative care.
Medical records must support medical necessity, be legible, and made available on request
Maintain medical records that fully support medical necessity; documentation should be legible, kept in the patient's record, and available upon request to support review.
- Records must include relevant medical history, physical exam, and results of diagnostic tests or procedures.
- Make documentation available and ensure legibility to facilitate review.
Ensure records fully support medical necessity and availability for review
Reinforce that the patient's medical record must fully support medical necessity and be available upon request; lack of documentation may prevent completion of review.
- Failure to provide adequate records can impede review and determination of coverage.
- Ensure complete documentation of history, exam, and diagnostic results.
Documentation risk: insufficient records may lead to denial
Lack of medical record documentation that fully supports medical necessity may result in denial because documentation must support clinical criteria for coverage.
- Insufficient or missing documentation of symptoms, duration, objective findings, or prior therapies risks denial as medical necessity cannot be established.
Appropriate patient selection: BSD requires symptoms plus positive CT
Do not perform BSD without both sinonasal symptoms and positive CT findings; CT scanning of the sinuses is a requirement before balloon dilation can be performed and is necessary for surgical planning.
- Balloon dilation is not appropriate for patients with sinonasal symptoms if CT does not show disease.
- Confirm symptom laterality matches CT findings for the sinus to be treated.
Antibiotic prescribing: only for significant/persistent purulence per guidelines
Do not prescribe antibiotics unless there is significant or persistent purulent nasal discharge; AAO‑HNS guidance discourages antibiotics without this finding and antibiotics should be used per guideline‑recommended indications.
- Document indication for antibiotics (significant/persistent purulence) when used.
- Avoid routine antibiotic prescribing in absence of guideline‑based indications to reduce nonconcordant care determinations.
Documentation insufficiency: inadequate records may prevent review or cause denial
Inadequate or missing medical record documentation supporting medical necessity may lead to denial or inability to complete the review; ensure documentation of symptoms, duration, objective findings, and prior therapies.
- Incomplete records may prevent authorization or result in denial.
- Provide complete timelines, imaging, and treatment trial documentation to facilitate review.
Documentation may trigger denial if medical necessity is not supported
Lack of adequate medical record documentation that fully supports medical necessity may lead to denial of coverage; documentation must be made available upon request for review.
- Providing records does not guarantee coverage; absence of required documentation risks denial.
- Ensure legible, organized records that clearly link symptoms, imaging, and prior therapy failures.
Definitions and Clinical Terms
Background and Clinical Context
Background: Rhinosinusitis includes acute, chronic (≥12 weeks), and recurrent forms and may be bacterial or viral. Balloon sinus ostial dilation (BSD) is a minimally invasive technique to dilate sinus ostia and can be used as a stand‑alone procedure or adjunct to FESS in selected patients. Functional endoscopic sinus surgery (FESS) is the established surgical approach for ethmoid, frontal, and maxillary disease and is indicated when guideline criteria and objective findings support more extensive tissue removal.
Policy Changes and Version History
Medical records documentation language was added clarifying that documentation may be requested to assess clinical criteria, listing required elements (medical history, physical exam, diagnostic test results), and noting documentation does not guarantee coverage.
Definitions for Acute Rhinosinusitis, Chronic Rhinosinusitis, Functional Endoscopic Sinus Surgery, Modified Lund-Mackay Scoring System, and Recurrent Acute Rhinosinusitis were updated.
A definition for Acute Bacterial Rhinosinusitis was added to the policy.
Definitions for the Draf Classification System for Endoscopic Frontal Sinus Drainage and Rhinitis Medicamentosa were removed.
Description of Services, Clinical Evidence, and References sections were updated and the prior policy version CS138KY.12 was archived.
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