Sinus Surgeries and Interventions (for New Mexico Only)
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This policy governs coverage criteria, definitions, evidence summary, and applicable codes for balloon sinus ostial dilation and functional endoscopic sinus surgery (FESS) for members in New Mexico.
Medical records documentation used for reviews: added language clarifying that medical records may be required to assess whether the member meets clinical criteria for coverage and that documentation must fully support medical necessity.
Definition of 'Acute Bacterial Rhinosinusitis' was added.
Definitions for Draf Classification System for Endoscopic Frontal Sinus Drainage and Rhinitis Medicamentosa (RM) were removed.
Updated definitions for Acute Rhinosinusitis, Chronic Rhinosinusitis, Functional Endoscopic Sinus Surgery, Modified Lund-Mackay Scoring System, and Recurrent Acute Rhinosinusitis.
Supporting Information section updated: Description of Services, Clinical Evidence, and References refreshed to reflect current information.
Coverage Criteria for Balloon Dilation and FESS
Initial coverage criteria for CRS and RARS
Covered when ALL of the following are met:
Applies to balloon dilation and/or FESS as specified
Specific to BSD
Indication for surgery if criteria met
FESS coverage extensions
FESS is also covered when ANY of the following CT-confirmed conditions are present:
These are standalone indications for FESS
Anatomic/CT findings required for FESS in specific sinuses
Indications for surgical intervention (BSD or FESS)
Covered when ALL of the following are met (per guideline and trial-based evidence):
Derived from AAO-HNS and ARS consensus statements and clinical practice guidance
ESS Coverage Criteria (evidence and guideline-aligned)
Covered when criteria consistent with specialty society guidance and clinical evidence are documented:
AAO‑HNS diagnostic criteria
AAAAI/ACAAI/JCAAI indications
AAO‑HNS and ACR recommendations
EUFOREA position paper
Multiple trials and systematic reviews (eg, Philpott et al., Tran et al., Fu et al., Lourijsen et al.)
Guideline-based clinical criteria
Covered when guideline-based clinical criteria are met (per cited bodies):
SNOT‑22 and Lund‑Mackay thresholds explicitly cited in EUFOREA and ICAR‑RS guidance
ACR appropriateness criteria cited
Insufficient evidence interventions
Not supported / insufficient evidence:
Hathorn et al. 2014 pilot study; policy conclusion that this technique is unproven and not medically necessary
Policy statements on insufficient evidence for BSD/FESS when criteria not met
AAO‑HNS consensus and cited trial evidence
Balloon sinus ostial dilation (BSD) and self-expanding absorptive devices are evaluated separately in this policy. BSD is unproven and not medically necessary for treatment of sinonasal polyps or tumors, and for cases of chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS) that do not meet the coverage criteria outlined elsewhere in this policy. The policy identifies self-expanding absorptive sinus ostial dilation (osmotic expansion devices) as investigational and not medically necessary for evaluating or treating sinusitis or any other conditions because evidence is limited and comparative effectiveness has not been established.
Functional endoscopic sinus surgery (FESS) is addressed separately and is considered medically necessary only when the policy’s specific criteria are met. When CRS or RARS presentations do not satisfy the documented clinical, endoscopic, and imaging requirements described in this policy, both FESS and BSD are deemed not medically necessary.
Balloon dilation is not appropriate for patients who lack both sinonasal symptoms and positive CT findings; policy aligns with AAO‑HNS consensus that BSD should not be used for asymptomatic imaging findings alone. BSD is also not appropriate for management of headache or sleep apnea in patients who do not otherwise meet CRS or RARS diagnostic criteria, as randomized trial data showed no benefit of ostial dilation over placebo for barometric pressure–related sinus headache when CT did not show mucosal disease.
An appropriate candidate for BSD or FESS must have sinonasal symptoms that correspond to objective evidence of sinonasal disease on nasal endoscopy or CT (eg, mucosal thickening, ostial obstruction). Requests for BSD without documentation of both ipsilateral symptoms and CT or endoscopic findings may be denied.
Surgeons should avoid imposing a required, predefined medical therapy algorithm as an absolute prerequisite to surgery; AAO‑HNS guidance states that medical therapy should be tailored to the patient and that the surgeon should avoid mandating specific regimens before recommending surgery. Likewise, the decision to operate should not be based solely on arbitrary imaging thresholds such as isolated mucosal thickening or percent opacification on CT without correlation to clinical symptoms and other objective findings.
Imaging and medical therapy are complementary elements of evaluation: CT (fine‑cut, non‑contrast maxillofacial protocol) is endorsed for preoperative planning, but imaging findings should be interpreted within the clinical context rather than used in isolation to justify procedural intervention.
FDA clearance or device marketing status is informational only; FDA approval or 510(k) clearance alone is not a basis for coverage. The FDA classifies devices used for balloon catheter dilation under product code LRC, and the SinuSys Vent‑OS device has received 510(k) clearance for maxillary sinus ostial dilation. Functional endoscopic sinus surgery is a surgical procedure and is not itself subject to FDA device regulation, although devices or implants used during the procedure may be regulated.
Self‑expanding absorptive devices such as the SinuSys Vent‑OS have been studied in small pilots but remain investigational pending comparative evidence of safety and effectiveness; FDA clearance of a specific device does not establish clinical utility for all indications addressed by this policy.
When the policy’s coverage criteria are not met (clinical symptoms, objective inflammation on endoscopy or CT, and documented failure of appropriate medical therapy where required), FESS and balloon dilation are considered not medically necessary. The policy requires that CRS be verified per guideline criteria (≥12 weeks with at least two cardinal symptoms plus objective evidence of inflammation) before surgical approaches are authorized.
Surgical intervention should be offered only when expected benefits outweigh nonsurgical treatments and when the member’s medical record documents the disease characteristics, prior therapies, and informed consent/expectations; absent such documentation, requests for FESS or BSD may be denied as not medically necessary.
Randomized trial evidence does not support use of BSD for barometric pressure–related sinus headache when CT lacks evidence of mucosal disease. Laury et al. randomized patients with sinus pressure headache but no mucosal thickening on CT to ostial balloon dilation versus placebo (nasal cavity dilation) and found no difference between groups in SNOT‑22 or HIT‑6 outcomes, indicating BSD did not provide incremental benefit over sham in this setting.
Consistent with that evidence, BSD for isolated headache complaints without objective sinonasal disease is unsupported and considered not medically necessary.
A randomized trial comparing early ESS, prolonged low‑dose clarithromycin, and placebo in patients with CRS who had failed intranasal medical therapy showed that ESS produced significantly greater improvement in disease‑specific quality of life (SNOT‑22) at 6 months compared with clarithromycin or placebo, while clarithromycin did not differ from placebo. The trial findings support offering surgery when intranasal medication alone is insufficient and indicate that prolonged low‑dose clarithromycin does not provide clinically meaningful benefit as an alternative to surgery in that trial population.
Policy implications: prolonged low‑dose macrolide therapy is not supported by this RCT as an effective substitute for ESS in appropriately selected patients and should not be substituted for meeting the policy’s surgical candidacy criteria.
The literature on self‑expanding absorptive sinus ostial dilation devices is limited to small pilot studies without control groups; for example, Hathorn et al. reported device placement in a small series with no adverse events but lacked comparative data and had a small sample size. Because of these limitations, the policy considers such devices unsupported by sufficient evidence for routine clinical use in sinusitis management and deems them not medically necessary.
Descriptions of the self‑expanding devices (mechanism of osmotic expansion) and the fact that some devices have received FDA clearance are noted in the policy, but the evidence base is insufficient to establish effectiveness compared with standard BSD or FESS approaches.
Applicable Codes and Related 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 LRC (instrument, ENT, manual surgical) — classification for devices used for balloon catheter dilation |
Prior Authorization, Documentation, and Preoperative Expectations
Obtain prior authorization for listed CPT codes
Prior authorization is required for the CPT codes listed for sinus procedures (see Applicable Codes appendix). Authorization should be requested when billing any of the included procedure codes (e.g., 31295–31299, 31240–31288) to determine coverage and payment.
- Applicable CPT codes are listed in the policy’s Applicable Codes section and their inclusion indicates prior authorization is required.
- Listing of a code does not guarantee reimbursement; check plan, federal/state/contractual rules.
Confirm CT imaging before BSD
Obtain and document a recent CT scan of the sinuses before balloon sinus dilation; CT must be performed after completion of medical management and demonstrate disease in the sinus(es) to be treated.
- AAO‑HNS and AAO statements: “CT scanning of the sinuses is a requirement before balloon dilation can be performed.”
- CT must show ostial occlusion or mucosal thickening consistent with the planned BSD site.
Submit preoperative CT and prior therapy details
Provide preoperative fine‑cut, non‑contrast maxillofacial CT images and documentation of prior medical therapy when requesting authorization; include Lund‑Mackay scoring or percent opacification and specify which sinuses are affected.
- Policy endorses a fine‑cut maxillofacial CT without contrast for surgical planning and expects documentation of disease extent (percent opacification or Modified Lund‑Mackay score).
- CT images should be obtained after completion of the required medical management described in the policy.
Verify benefit and prior‑review requirements
Verify applicable federal, state, and contractual benefit requirements before applying this policy; coverage decisions may require prior review and submission of medical records to demonstrate medical necessity.
- Instructions for Use: check federal, state, or contractual benefit plan terms before using the policy.
- Medical records may be requested to assess whether the member meets clinical criteria and do not guarantee coverage.
Document completion and failure of specified medical therapy
Document completion and failure of required medical management prior to surgery: intranasal corticosteroids (± oral corticosteroids when appropriate), antibiotic therapy if bacterial infection is suspected, and nasal lavage/irrigation when appropriate.
- Coverage requires persistence of symptoms despite recent medical management including full courses of intranasal corticosteroids and antibiotics when indicated, plus nasal irrigation if appropriate.
- AAA/ACAAI/JCAAI guidance notes intranasal corticosteroids are indicated and antibiotics reserved for suspected bacterial infection.
Support surgical candidacy with randomized‑trial evidence when relevant
When asserting surgery is indicated after failed medical therapy, cite randomized trial evidence showing ESS improved SNOT‑22 versus medical therapy; include that ESS produced significantly lower SNOT‑22 scores at 6 months compared with clarithromycin or placebo in a randomized trial of 514 patients.
- Philpott et al. trial (n=514): ESS group had significantly lower SNOT‑22 at 6 months vs clarithromycin and placebo.
- Use trial results to support surgery when intranasal medication alone is insufficient.
Document tailored medical therapy per guideline expectations
Follow guideline recommendations to tailor medical therapy before surgery; a minimum trial such as ≥8 weeks of topical intranasal corticosteroid plus adjunctive antibiotic strategy is referenced in EUFOREA and ICAR‑RS guidance.
- EUFOREA: for uncomplicated CRSsNP, a minimum trial ≥8 weeks of topical intranasal corticosteroid plus a short systemic antibiotic or prolonged low‑dose antiinflammatory antibiotic is recommended.
- ICAR‑RS and AAO‑HNS recommend tailored medical therapy rather than mandating a single predefined regimen.
Record pre‑surgical medical therapy and symptom scores
Although not a formal step‑therapy program, document a guideline‑consistent trial of medical therapy (e.g., ≥8 weeks topical intranasal corticosteroid plus adjunctive antibiotic or prolonged low‑dose antiinflammatory antibiotic) and symptom scoring (SNOT‑22) prior to offering ESS in applicable cases.
- EUFOREA specifies ≥8‑week trial and posttreatment SNOT‑22 ≥20 for offering ESS in uncomplicated CRSsNP.
- ICAR‑RS notes SNOT‑22 ≥20 and evidence of inflammation on endoscopy or CT as criteria for ESS candidacy.
Maintain required medical record documentation
Ensure the medical record contains the full history, focused physical exam, and pertinent diagnostic test results; when required by policy, include a CT performed within 12 months of the planned procedure.
- Medical records must fully support medical necessity and be legible and available upon request.
- Recent CT is defined as within 12 months for purposes of this policy.
Provide objective endoscopy or CT evidence
Include objective evidence of sinonasal inflammation: document nasal endoscopy findings (edema, polyps, purulence, or middle meatal abnormalities) or CT evidence (mucosal thickening, ostial occlusion, opacification) that corresponds to the symptomatic side.
- AAO‑HNS and ARS guidance: clinical diagnosis should be supported by nasal endoscopy or CT demonstrating mucosal thickening or ostial occlusion.
- Policy requires sinonasal symptoms to be present on the same side as CT findings for coverage.
Document CRS diagnosis per guideline criteria
Document that the patient meets CRS diagnostic criteria per guidelines: symptoms ≥12 weeks with at least two cardinal symptoms and objective evidence of inflammation on endoscopy or imaging.
- AAO‑HNS diagnosis: ≥12 weeks plus ≥2 symptoms (eg, nasal drainage, obstruction, facial pain, or diminished smell).
- Documentation must include evidence of inflammation by endoscopy or CT.
Provide legible, supporting medical records upon request
Be prepared to supply complete medical records on request; records must fully support the medical necessity for the requested services, or the request may be denied.
- Policy change clarifies medical records documentation may be required and must fully support medical necessity.
- Lack of adequate records does not guarantee coverage and may prompt denial.
Avoid documentation‑based denial triggers
Failure to document completion and failure of required medical therapy, absence of a recent CT demonstrating disease in the sinus(es) to be treated, or lack of sinonasal symptoms on the same side as CT findings are specific documentation‑based denial triggers.
- Policy states coverage requires persistence of symptoms despite recent medical management and CT confirmation after medical management.
- Policy notes lack of records documenting failed medical management or absence of recent CT may trigger denial.
Do not perform BSD without symptoms plus positive CT
Do not submit BSD for patients without both sinonasal symptoms and positive CT findings; AAO‑HNS consensus and policy require CT evidence before BSD and consider BSD inappropriate when CT lacks disease.
- AAO‑HNS consensus: “Balloon dilation is not appropriate for patients who are without both sinonasal symptoms and positive findings on CT.”
- AAO‑HNS: “CT scanning of the sinuses is a requirement before balloon dilation can be performed.”
Document informed consent and expected surgical benefits
Document the discussion of risks, expected advantages, likely outcomes, and long‑term management expectations; surgery should be offered only when expected advantages outweigh nonsurgical treatments and informed consent/expectations are recorded.
- AAO‑HNS: “Sinus surgery should be offered when the expected advantages of surgery outweigh those of nonsurgical treatments… and the patient is informed about the long‑term disease management required after surgery.”
- Surgeon should discuss expectations and postoperative care with the patient.
Recognize documentation‑dependent denial risk
Requests lacking complete documentation to support medical necessity for the requested services may be denied; ensure records include history, exam, imaging/endoscopy, prior therapies, and symptom scores to reduce risk of denial.
- Policy history: added language that medical records must fully support medical necessity and may be requested.
- Medical records documentation may be required to assess whether the member meets clinical criteria; insufficient documentation risks denial.
Key Definitions
Rhinosinusitis encompasses both acute and chronic forms. Chronic Rhinosinusitis (CRS) is defined by symptoms persisting for at least 12 weeks and requires at least two cardinal symptoms (for example, thick or discolored nasal drainage, nasal obstruction, facial pain/pressure/fullness, or diminished sense of smell) plus objective evidence of inflammation on nasal endoscopy or radiologic imaging. Balloon sinus ostial dilation and FESS are procedures intended to restore sinus drainage and ventilation by addressing ostial obstruction and mucosal disease; BSD may be performed as a stand-alone technique or adjunctively with FESS.
Background, Clinical Evidence, and Rationale
Balloon sinus ostial dilation (BSD) — also called balloon sinuplasty or balloon catheter sinusotomy — dilates sinus ostia via a transnasal or transantral approach by inflating a balloon to widen the outflow tract. Potential advantages described in the literature include less mucosal trauma, minimal intraoperative bleeding, and shorter recovery time; BSD may be performed alone or in combination with FESS as a hybrid approach. FESS is a minimally invasive endoscopic surgery to remove anatomic obstructions and diseased tissue to reestablish normal sinus ventilation and drainage. Clinical trial and guideline evidence indicate that surgical intervention is appropriate when CRS or RARS diagnostic criteria are met, objective inflammation is documented, and patients have failed appropriate medical management; isolated indications without objective disease (for example, barometric pressure–related headache without CT evidence) have not demonstrated benefit from BSD.
Policy Revision History and Material Changes
Added and operationalized a requirement that medical records documentation may be requested for reviews and must fully support medical necessity; clarified that documentation must be legible and made available upon request; updated related definitions and supporting information.
Added definition for 'Acute Bacterial Rhinosinusitis' and updated definitions for Acute Rhinosinusitis, Chronic Rhinosinusitis, Functional Endoscopic Sinus Surgery, Modified Lund-Mackay Scoring System, and Recurrent Acute Rhinosinusitis; removed Draf Classification and Rhinitis Medicamentosa definitions.
Refreshed the Supporting Information section including Description of Services, Clinical Evidence, and References to reflect current information.
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