ModifiedUnitedHealthcarePolicy SRST2026T0571U

Sinus Surgeries and Interventions

Clinical coverage criteria and evidence summary for balloon sinus ostial dilation (balloon sinuplasty) and functional endoscopic sinus surgery (FESS) for chronic and recurrent rhinosinusitis, describing when procedures are considered medically necessary and when they are unproven/not medically necessary; intended for UnitedHealthcare providers and claim reviewers.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions

Policy CodePolicy SRST2026T0571U

Change TypeMaterial updates and code removal

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument failed appropriate medical therapy and provide recent CT or endoscopy demonstrating objective disease before submitting authorization.

SourceLink

POLICY UPDATE CHANGES

Removed language indicating self-expanding absorptive sinus ostial dilation is unproven and not medically necessary for evaluating or treating sinusitis and all other conditions due to insufficient evidence of efficacy.

Removed CPT code 31299.

Added reference link to the Medical Policy titled Rhinoplasty and Other Nasal Procedures.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information.

Removed Medical Records Documentation Used for Reviews section; archived previous policy version 2026T0571T.

04/01/2026Policy revision date

26.02Mean SNOT-22 change after ESS

17%10-year ESS revision rate

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

1076Long-term ESS cohort

Coverage Criteria and Medical Necessity

Initial surgical eligibility

Initial surgical eligibility — Covered when ALL of the following are met:

ALL of the following

Documented diagnosis of Chronic Rhinosinusitis (CRS) or Recurrent Acute Rhinosinusitis (RARS) based on clinical history (sinonasal symptoms such as nasal obstruction, facial pain/pressure, purulent drainage, or olfactory disturbance) consistent with society guidance.
Symptoms have persisted for an appropriate duration: for CRS, symptoms present for longer than 12 weeks; for RARS, four or more discrete episodes per year with symptom-free intervals between episodes.
Failure of appropriate maximal medical therapy (MMT) prior to consideration of surgery, including all of the following as clinically appropriate: intranasal corticosteroids (and/or short course oral corticosteroids when indicated); antibiotic therapy if bacterial infection is suspected; and saline nasal irrigation/lavage.
Objective evidence of disease on sinonasal imaging or endoscopy: CT of the paranasal sinuses obtained after completion of medical management demonstrating disease in the sinus(es) proposed for treatment (examples: mucosal thickening, ostial obstruction/outflow tract obstruction, opacification, or bony remodeling) and/or nasal endoscopy documenting mucosal inflammation, purulence, or nasal polyposis as applicable.
Correlation between symptoms and objective findings: sinonasal symptoms are present on the same side(s) as the CT or endoscopy findings for the sinus(es) to be treated.
For balloon sinus ostial dilation specifically, the intended dilation is limited to frontal, maxillary, or sphenoid sinus ostia (not for treatment of diffuse polyposis or sinonasal tumors).
For patients being considered for FESS, CT imaging must provide the anatomic detail necessary to plan surgery, and imaging is generally obtained after optimal medical therapy.

Pediatric surgical pathway

Pediatric surgical pathway — Covered when ALL of the following are met:

ALL of the following

Pediatric patient with a documented diagnosis of chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS) based on age-appropriate clinical criteria and sinonasal symptoms consistent with disease.
Failure of appropriate maximal medical therapy for an adequate duration per pediatric practice guidance prior to surgical consideration (e.g., topical intranasal corticosteroids and appropriate courses of antibiotics when indicated, saline irrigation).
AAO-HNS pediatric CRS guidance recommends consideration of adenoidectomy as first-line surgical intervention in many children prior to sinus surgery.
Clinical consideration that adenoidectomy has been strongly considered and/or performed when appropriate, and a minimum three-month period following adenoidectomy has elapsed without adequate clinical improvement before undertaking sinus surgery, unless clinical circumstances justify earlier intervention.
Per AAO-HNS pediatric indicators: adenoidectomy should be strongly considered a minimum of three months prior to pediatric sinus surgery.

Provider Authorization, Documentation, and Preoperative Requirements

Prior Authorization

Prior Authorization Requirements (Clinical Documentation)

Prior authorization is required for referenced endoscopic sinus and sinus dilation procedures. Submit clinical documentation at time of PA request to demonstrate that criteria below are met. Verify member’s benefit plan and any additional PA requirements; supply operative reports, CT images/reports, endoscopy findings, and documentation of prior medical therapy as requested.

PA may be required for surgical CPT codes listed in the Applicable Codes section — confirm current applicable CPT codes prior to authorization.
Include copies of recent CT images/reports and nasal endoscopy findings when available.

Denial Risk

Required Clinical Documentation and Denial Risk

Document objective evidence of sinonasal inflammation and that the patient has failed appropriate maximal medical therapy prior to elective endoscopic sinus surgery or balloon sinuplasty. Lack of required documentation may result in denial.

Procedure, Device, and Scoring Codes

Applicable Procedure CPT CodesCPT

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.

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Removed/Updated CPT CodesCPTNot Covered

31299

CPT code 31299 (removed from policy applicable codes list)

FDA Product Codes (informational)mixed

LRC	FDA product code LRC — instrument, ENT, manual surgical (classification for balloon dilation devices); product code is 510(k)-exempt.

inv-20: RARS episode threshold

RARS episode thresholdFour or more episodes per year (>= 4 episodes/year)

Episode definitionDistinct symptom-free intervals between episodes; episodes should meet ABRS diagnostic criteria or be documented during an episode

Confirmation preferredConfirming a true bacterial episode via laboratory analysis is preferred; clinical exam during an episode may substantiate diagnosis

inv-21: Recent CT

Recent CT requirementCT scan performed within 12 months of the planned procedure

Timing relative to medical therapy

Key Definitions and Scoring Systems

inv-41: Chronic Rhinosinusitis (CRS) definition

CRS durationInflammation of the paranasal sinuses persisting for longer than 12 weeks

Required symptoms (two or more)Mucopurulent drainage; nasal obstruction (congestion); facial pain/pressure/fullness; or decreased sense of smell

Objective documentationInflammation must be documented by polyps, edema, purulent mucus on exam, or radiographic imaging showing sinus inflammation

inv-42: Recurrent Acute Rhinosinusitis (RARS)

RARS definitionFour or more episodes per year of acute bacterial rhinosinusitis (>= 4 episodes/year) with distinct symptom-free intervals

Episode diagnostic criteriaEach episode should meet ABRS criteria: failure to improve within 10 days, or worsening after initial improvement, or confirmed bacterial infection

Background and Evidence Summary

Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses that persists for more than 12 weeks and is characterized by two or more symptoms such as mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or reduced smell, combined with objective evidence of sinonasal inflammation on examination, endoscopy, or imaging. FESS and balloon sinus ostial dilation are surgical options for medically refractory CRS or for certain complications; balloon dilation may be used as a standalone procedure for limited disease or adjunctively with FESS, and it may offer less mucosal trauma and faster recovery in appropriately selected patients.

Policy Revision History

2026-04-01policy_revisionLatest

Removed language that had labeled self-expanding absorptive sinus ostial dilation as unproven and not medically necessary; removed CPT code 31299 from the applicable codes list; and updated the Description of Services, Clinical Evidence, FDA, and References sections.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions

Policy CodePolicy SRST2026T0571U

Change TypeMaterial updates and code removal

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument failed appropriate medical therapy and provide recent CT or endoscopy demonstrating objective disease before submitting authorization.

SourceLink

On This Page

Objective documentation of sinus disease by CT imaging or nasal endoscopy when surgery is being planned: a CT demonstrating sinonasal inflammation or mucosal disease in the sinus(es) proposed for treatment (obtain imaging after medical therapy when feasible).

For balloon sinuplasty in children, the evidence is insufficient to conclude superiority to traditional ESS; effectiveness cannot be determined based on current pediatric evidence.

Surgical selection tailored to pediatric anatomy and disease severity: limited procedures (e.g., targeted ostial dilation) reserved for appropriately selected children with localized disease and lacking diffuse polyposis, with comprehensive ESS considered for more extensive disease or when indicated.

Record duration of symptoms (e.g., ≥ 12 weeks for CRS) and symptom severity (SNOT-22 when available).
Provide documentation of failure of appropriate medical therapy (see medical management bullets).
Provide objective confirmation of disease by nasal endoscopy and/or CT of the paranasal sinuses showing mucosal thickening, ostial obstruction, opacification, or other relevant findings.
For RARS, document frequency of discrete episodes (e.g., ≥4 per year) with symptom-free intervals and correlating CT/endoscopy findings.

Documentation Required

Medical Management and Preoperative Imaging

Optimal medical therapy should be attempted and documented before surgical consideration. Documentation should include the specific medical therapies tried, duration, and response. Imaging is generally obtained after a trial of medical management when surgery is being considered.

Medical management to document may include: saline irrigation/nasal lavage, topical intranasal corticosteroids (INS), short course oral corticosteroids when appropriate, and antibiotics when bacterial infection is suspected.
Maximal medical therapy (MMT) may include prolonged topical INS, adjunctive therapies (decongestants, intranasal antihistamines), mucolytics, and culture-directed or prolonged antibiotics when indicated.
Document duration of therapies (e.g., minimum 8 weeks of topical INS plus adjunctive antibiotic regimen when applicable per specialty guidance).
Obtain CT of the paranasal sinuses when ESS or balloon dilation is being considered; imaging should demonstrate objective disease and is typically done after a trial of medical therapy.

Prior Authorization

Balloon Sinuplasty / XprESS Authorization Considerations

Balloon sinuplasty / sinus ostial dilation may be considered only for selected patients and requires both clinical and imaging confirmation. For dilation procedures, CT evidence specific to the targeted sinus (ostial obstruction and mucosal thickening) and documentation of failed medical therapy are expected.

Balloon dilation is appropriate only when the patient has both sinonasal symptoms and positive CT findings for the sinus to be dilated (frontal, maxillary, or sphenoid).
CT scanning of the sinuses is required prior to balloon dilation.
Dilation is generally limited to frontal, maxillary, or sphenoid sinuses per coverage rationale; document which sinus(es) will be treated and CT-based extent of disease (percent opacification or Lund-Mackay score).
Balloon dilation may be considered for select patients with CRS without severe nasal polyposis or for RARS when ostial occlusion and mucosal thickening are present on CT.

Imaging should generally be obtained after completion of appropriate medical management and within 12 months

PurposeCT documents which sinuses have disease and extent of disease (percent opacification or modified Lund-Mackay) for surgical planning

inv-22: CT Lund-Mackay score

CT Lund-Mackay thresholdLund-Mackay score >= 1 (EUFOREA threshold for offering ESS in uncomplicated CRSsNP when other criteria met)

Scoring system basisModified Lund-Mackay assigns scores per sinus based on percent opacification (0–5) with ostiomeatal complex 0–2; total maximum 54

Clinical useThreshold referenced by EUFOREA as one criterion among others (including symptom duration and SNOT-22) for surgical consideration

inv-23: SNOT-22 threshold

SNOT-22 thresholdSNOT-22 score >= 20 (referenced by ICAR-RS and EUFOREA as part of criteria for surgical consideration)

ContextUsed as a patient-reported outcome to support eligibility for ESS after failure of maximal medical therapy

Combined criteriaEUFOREA pairs SNOT-22 >=20 with Lund-Mackay >=1 and an 8-week trial of intranasal corticosteroid plus antibiotics where indicated

Confirmation guidanceConfirming a true bacterial episode by laboratory analysis is preferred; examination during an episode can substantiate diagnosis

inv-43: Recent CT Scan definition

Recent CT Scan definitionA CT scan performed within 12 months of the planned procedure

RoleCT provides objective evidence of sinus disease and documents extent/opacification for each sinus to be treated

Timing noteCT should generally be obtained after completion of appropriate medical management when used for surgical planning

inv-44: Modified Lund-Mackay Scoring System

Modified Lund-Mackay systemEach sinus scored 0–5 based on percent opacification (0=0%, 1=1–25%, 2=26–50%, 3=51–75%, 4=76–99%, 5=100%); OMC scored 0–2; total maximum 54

PurposeQuantifies CT-based severity of CRS and guides extent of surgery planning

Reference studyZinreich modification described; Likness et al. compared methods and reports total max 54

inv-45: RARS (term reiteration)

RARS contextRARS denotes recurrent acute bacterial rhinosinusitis with multiple discrete ABRS episodes during a defined period and may be an indication for SOD when CT/endoscopy confirm ostial occlusion and mucosal thickening

SOD roleAAO-HNS notes a role for balloon dilation in RARS when defined criteria and CT evidence are present

Episode confirmationOne episode should be confirmed via CT or endoscopy per guidance when surgical treatment is considered

inv-46: BSD / SOD definition

Balloon sinus ostial dilation (BSD/SOD)Dilation of paranasal sinus ostia using balloon catheter techniques (balloon sinuplasty), performed standalone or adjunctively with FESS

Device classificationDevices for balloon dilation are classified under FDA product code LRC (instrument, ENT, manual surgical) and are 510(k)-exempt

Clinical roleCan be used for limited/uncomplicated disease (frontal, maxillary, sphenoid ostia) or adjunct to FESS per guideline recommendations

inv-47: Uncomplicated CRS definition

Uncomplicated CRS definitionCRS without severe nasal polyposis or other complicating features (may be appropriate for balloon dilation per NICE/EUFOREA guidance)

Candidate selectionNICE recommends XprESS for uncomplicated CRS in patients without severe nasal polyposis; EUFOREA supports offering ESS or balloon approaches in selected mild cases

ImplicationPresence of severe nasal polyposis or other complicating features typically excludes balloon-only approaches

inv-48: Balloon sinuplasty / ostial dilation device description

Device descriptionBalloon sinuplasty/ostial dilation uses balloon catheters to dilate sinus ostia; devices fall under FDA product code LRC

Regulatory noteProduct code LRC is 510(k)-exempt; device listing is informational and FDA clearance alone is not a basis for coverage

Use casesDevices may be used standalone for limited ostial dilation (frontal, maxillary, sphenoid) or as adjuncts during FESS

inv-49: Lund-Mackay score

Lund-Mackay scoring basicsCT-based scoring for sinus opacification; modified system assigns 0–5 per sinus with OMC 0–2; total max 54

EUFOREA thresholdEUFOREA references Lund-Mackay >= 1 as a CT criterion for offering ESS in uncomplicated CRSsNP when combined with other criteria

Clinical applicationUsed alongside symptom duration and SNOT-22 to determine surgical candidacy per consensus recommendations