ModifiedUnitedHealthcare Community PlanPolicy CSNCT0571.07

Sinus Surgeries and Interventions (for North Carolina Only)

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Coverage criteria for sinus surgeries and interventions, including FESS, balloon sinus ostial dilation, and self-expanding absorptive sinus ostial dilation, for UnitedHealthcare Community Plan members in North Carolina.

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ModifiedUnitedHealthcare Community PlanPolicy CSNCT0571.07

Sinus Surgeries and Interventions (for North Carolina Only)

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Sign up for UnitedHealthcare Policy CSNCT0571.07 alerts

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Policy Summary

PayerUnitedHealthcare Community Plan

PolicySinus Surgeries and Interventions (for North Carolina Only)

Policy CodePolicy CSNCT0571.07

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor balloon sinus ostial dilation, use North Carolina Medicaid Clinical Coverage Policy 1A-42 for medical-necessity and coverage criteria.

SourceLink

POLICY UPDATE CHANGES

Balloon sinus ostial dilation criteria were clarified to reference North Carolina Medicaid Clinical Coverage Policy 1A-42.

Non-state-specific language for several services, including balloon ostial dilation definitions and criteria, was removed.

Medical-record documentation requirements were added.

The definition of acute bacterial rhinosinusitis was added, and several existing clinical definitions were revised.

The policy clarifies that balloon sinus ostial dilation medical-necessity criteria must be obtained from North Carolina Medicaid Clinical Coverage Policy 1A-42.

North CarolinaApplicable state

≥4/yearRARS threshold

12 monthsRecent CT window

5CT-related FESS indications

Not medically necessarySelf-expanding absorptive dilation

1A-42Referenced NC policy

Medical Necessity and Coverage Criteria

FESS for recurrent acute rhinosinusitis

FESS is proven and medically necessary for recurrent acute rhinosinusitis when all of the following are met.

RARS FESS criteria

Episode frequency: Four or more episodes per year with distinct symptom-free intervals between episodes.≥4 episodes/year
Clinical-imaging concordance: Sinonasal symptoms such as pain, pressure, or drainage are present on the same side as CT findings of rhinosinusitis.Ipsilateral symptoms and CT findings
Recent CT evidence
- Sinus-specific CT findings
  - Maxillary, frontal, or sphenoid sinus: Ostial obstruction and mucosal thickening are both present in the sinus to be treated.Both findings required
  - Ethmoid sinus: Mucosal thickening is present.Mucosal thickening

FESS for CT-confirmed conditions

FESS is also proven and medically necessary when any one of the following conditions is confirmed on CT.

CT-confirmed FESS indications

Complications of sinusitis such as abscess.CT confirmation
Concha bullosa: Symptomatic concha bullosa.CT confirmation
Mucocele: Symptomatic mucocele.CT confirmation
Polyposis with obstructive symptoms.

North Carolina state-specific criteria

Apply the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Physician, 1A-42, for the following services.

State-specific criteria referral

Balloon sinus ostial dilation: Refer to North Carolina Medicaid Clinical Coverage Policy, Physician, 1A-42: Balloon Ostial Dilation.
FESS for chronic rhinosinusitis: Refer to North Carolina Medicaid Clinical Coverage Policy, Physician, 1A-42: Balloon Ostial Dilation.

Unproven and not medically necessary services

The following services are unproven and not medically necessary.

Unproven services

FESS without policy criteria: FESS for CRS or RARS that does not meet the stated criteria.Criteria not met
Insufficient evidence of efficacy.
Self-expanding absorptive sinus ostial dilation: Evaluation or treatment of sinusitis and all other conditions using self-expanding absorptive sinus ostial dilation.Any condition
Insufficient evidence of efficacy.

Balloon sinus ostial dilation selection

Sinus ostial dilation may be appropriate when the following selection factors are present.

Selected CRS or RARS patient: The patient has a clinical diagnosis of CRS or RARS based on sinusitis-related symptoms.

Failure of appropriate medical therapy: The patient has experienced failure of medically appropriate therapy.

Objective sinonasal disease: Nasal endoscopy documents sinonasal abnormality or paranasal-sinus CT demonstrates mucosal thickening, ostial occlusion, or other positive findings.

CT scanning is required before balloon dilation.

Potential balloon dilation indications

Potentially favorable clinical contexts described in the evidence.

Appropriate disease context: Balloon dilation may be considered as an adjunct to FESS in CRSsNP; for selected RARS with CT evidence of ostial occlusion or mucosal thickening; for limited CRS without polyposis; for uncomplicated CRS without severe nasal polyposis; for frontal sinusitis; or for persistent disease after previous sinus surgery.

These are guideline or consensus-based contexts, not a complete coverage determination.

ESS after failed medical therapy

Evidence supporting ESS after inadequate medical treatment.

CRS with insufficient response to medical therapy: Studies summarized in this section evaluated ESS in patients with CRS, including CRSwNP, who had failed or had insufficient response to appropriate medical treatment; ESS improved disease-specific quality of life compared with continued medical therapy or prolonged clarithromycin in the cited trials.

This evidence summary does not establish the full policy coverage criteria.

CRS diagnosis

Clinical diagnosis framework for adult CRS.

Adult CRS diagnosis

Persistent symptoms: Symptoms are present for 12 weeks or longer with at least two of the following: thick or discolored nasal drainage, nasal obstruction, facial pain, pressure, or fullness, or diminished sense of smell.12 weeks or longer; at least 2 symptoms
Objective inflammation: Inflammation is documented by anterior rhinoscopy, nasal endoscopy, or CT, including edema or abnormal mucus in the middle meatus or anterior ethmoid region, nasal or middle-meatus polyps, or radiologic paranasal sinus inflammation.At least 1 objective finding

Sinus surgery candidacy

Clinical candidacy considerations for sinus surgery.

Surgical candidacy: Consider disease characteristics, quality of life, symptoms, previous medical and surgical therapy, expected advantages over nonsurgical treatment, understood outcomes, and the need for long-term disease management.

Surgery should be offered when expected advantages outweigh nonsurgical treatment alone and the patient understands likely outcomes and ongoing disease management.

Guideline-based ESS eligibility

EUFOREA and ICAR-RS criteria cited for ESS in selected CRS patients.

ESS clinical eligibility factors

Uncomplicated adult CRSsNP example: CT Lund-Mackay score ≥1 plus at least 8 weeks of topical intranasal corticosteroid therapy and either a short course of broad-spectrum or culture-directed systemic antibiotic or prolonged low-dose anti-inflammatory antibiotic therapy.Lund-Mackay ≥1; medical therapy ≥8 weeks; post-treatment SNOT-22 ≥20
EUFOREA 2020 example criteria.
Maximal medical therapy indicators: At least two cardinal symptoms for 12 weeks or more, SNOT-22 preoperative score ≥20, sinus inflammation or purulence on nasal endoscopy, and sinus inflammation on CT are cited as factors confirming maximal medical therapy and ESS eligibility.Symptoms ≥12 weeks; SNOT-22 ≥20
ICAR-RS 2021 criteria are described as including, but not limited to, these factors.

Extent of surgery for selected disease

Procedure-selection recommendation.

Complete sinus exposure when specific disease is present: In patients with sinus polyps, osteitis, bony erosion, or fungal disease, perform surgery involving complete exposure of the sinus lumen and removal of diseased tissue rather than relying solely on balloon or manual ostial dilation.Polyps, osteitis, bony erosion, or fungal disease

AAO-HNS recommendation cited in the policy.

Self-expanding absorptive sinus ostial dilation is excluded as a medically necessary service for evaluating or treating sinusitis and all other conditions.

Balloon sinus ostial dilation is not appropriate unless the patient has both sinonasal symptoms and positive objective findings on sinus CT. It is also not appropriate when symptoms are present but CT does not show sinonasal disease.

Balloon dilation is not appropriate to manage headache or sleep apnea when the patient does not otherwise meet criteria for chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS).

NICE guidance supports consideration of the XprESS multisinus dilation system for uncomplicated chronic rhinosinusitis in patients without severe nasal polyposis. NICE reported that, in this population, XprESS works as well as FESS, may allow faster recovery, and can more often be performed under local anesthesia.

The extent of sinus surgery, including which sinuses to treat, should not be determined solely by arbitrary imaging thresholds. Mucosal thickening, sinus opacification, or outflow obstruction on CT should not be the only basis for recommending intervention or determining the surgical extent.

Evidence supporting self-expanding absorptive sinus ostial dilation devices is insufficient. The available literature is limited by small sample sizes and the lack of comparison groups.

FDA approval or clearance alone is not a basis for coverage. Coverage depends on the applicable medical-necessity and clinical-coverage criteria, not solely on regulatory status.

FESS for chronic rhinosinusitis or recurrent acute rhinosinusitis that does not meet the applicable policy criteria is considered unproven and not medically necessary because evidence of efficacy is insufficient.

Self-expanding absorptive sinus ostial dilation is unproven and not medically necessary for evaluating or treating sinusitis or any other condition because evidence of efficacy is insufficient.

Coding and Threshold Reference

Applicable 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.

1–10 of 16

1/2

FDA device product codemixed

LRC	Instrument, ENT, manual surgical

Recurrent Acute Rhinosinusitis Threshold

Episode frequencyFour or more episodes per year

Episode patternDistinct symptom-free intervals between episodes

Clinical useThreshold used in defining recurrent acute rhinosinusitis and evaluating FESS eligibility

Recent CT Scan

DefinitionA CT scan performed within 12 months of the planned procedure

Time limit12 months

Application

Provider Documentation and Action Items

Prior Authorization

Sinus CT Required Before Balloon Dilation

Obtain a sinus CT before performing balloon sinus ostial dilation. CT imaging is a prerequisite for the procedure.

Document the CT in the medical record before balloon dilation is performed.

Documentation Required

Document Diagnosis and Failed Medical Therapy

Before considering sinus ostial dilation, establish a clinical diagnosis of CRS or RARS based on sinusitis-related symptoms and objective evidence, and document failure of appropriate medical therapy.

Objective evidence may include nasal endoscopy showing sinonasal abnormalities or CT showing paranasal sinus mucosal thickening.
Document the applicable CRS or RARS diagnosis and the patient's response to medically appropriate therapy.

Clinical Background

Rhinosinusitis is inflammation of the nasal cavities and paranasal sinuses and may be classified by duration and presumed cause. Chronic rhinosinusitis persists for more than 12 weeks. Recurrent acute rhinosinusitis consists of at least 4 acute bacterial rhinosinusitis episodes per year with complete resolution of signs and symptoms between episodes.

Policy Definitions and Abbreviations

Acute Bacterial Rhinosinusitis

ConditionAcute rhinosinusitis presumed or confirmed to be caused by bacterial infection

Initial courseSymptoms show no improvement within 10 days or more after onset of upper respiratory symptoms

Worsening courseSymptoms worsen within 10 days after initial improvement

Acute Rhinosinusitis

ConditionInflammation of the nasal cavities and paranasal sinuses

Associated symptomsThick or discolored nasal drainage and/or nasal obstruction, with facial pain, pressure, or fullness

Duration

Policy Summary

PayerUnitedHealthcare Community Plan

PolicySinus Surgeries and Interventions (for North Carolina Only)

Policy CodePolicy CSNCT0571.07

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateNot specified

Key ActionFor balloon sinus ostial dilation, use North Carolina Medicaid Clinical Coverage Policy 1A-42 for medical-necessity and coverage criteria.

SourceLink

On This Page

Tumor: Sinonasal tumor.CT confirmation

Used for CT evidence supporting the planned sinus procedure

Lund-Mackay Score Associated With FESS Benefit

ThresholdLund-Mackay CT score greater than or equal to 13.1

ProcedureFunctional endoscopic sinus surgery (FESS)

Evidence contextA score of 13.1 or greater was identified as a long-term predictor of FESS efficacy in CRS

Topical Intranasal Corticosteroid Trial

Minimum trialAt least 8 weeks

TherapyTopical intranasal corticosteroid

UsePart of the cited medical-therapy criteria for ESS in uncomplicated adult CRSsNP

CT Lund-Mackay Score

ThresholdCT Lund-Mackay score greater than or equal to 1

Required findingThe CT scan must show evidence of disease

Clinical contextCited as a criterion for ESS in adult patients with uncomplicated CRSsNP

SNOT-22 Preoperative Score

ThresholdSNOT-22 preoperative score greater than or equal to 20

TimingThe score is assessed preoperatively; EUFOREA also cites a post-treatment total score

Clinical contextCited as a factor confirming maximal medical therapy and ESS eligibility

CRS Symptom Duration

Minimum duration12 weeks or longer

Required symptomsAt least two cardinal symptoms, such as drainage, obstruction, facial pain or pressure, or diminished sense of smell

Clinical contextPersistent symptoms of this duration support the clinical diagnosis of chronic rhinosinusitis

Postoperative Follow-up

Follow-up intervalWithin 3 to 12 months after surgery

Assessment elementsPatient medical history and nasal endoscopy

PurposeThoroughly assess surgical outcomes

Unsupported block type: prior_auth

Unsupported block type: documentation

Unsupported block type: prior_auth

Unsupported block type: documentation

Unsupported block type: denial_risk

Unsupported block type: prior_auth

Unsupported block type: denial_risk

Persists for 4 weeks or less

Functional Endoscopic Sinus Surgery (FESS)

Procedure typeMinimally invasive surgical procedure

TechniqueUses specialized endoscopic instruments to access, diagnose, and treat the sinus passages

ObjectiveRestores normal sinus drainage and ventilation while preserving the mucosal lining

Modified Lund-Mackay Scoring System

Assessment toolCT-based tool for objectively evaluating sinus opacification

Anatomic areasEvaluates five sinuses, the ostiomeatal complexes, and nasal cavities

Scoring rangeOstiomeatal complexes are scored from 0 to 2, sinus and nasal cavity opacification from 0 to 4, with a maximum total score of 44

Recent Computed Tomography Scan

DefinitionA CT scan performed within 12 months of the planned procedure

ModalityComputed tomography scan

Policy timingThe scan is considered recent when it falls within the 12-month period before the planned procedure

Recurrent Acute Rhinosinusitis

Underlying conditionAcute bacterial rhinosinusitis

FrequencyFour or more episodes per year

Between episodesNo signs or symptoms between episodes

CRS

AbbreviationCRS

ExpansionChronic rhinosinusitis

Clinical durationSymptoms are generally present for 12 weeks or longer

RARS

AbbreviationRARS

ExpansionRecurrent acute rhinosinusitis

Defining patternAcute bacterial rhinosinusitis with four or more episodes per year and no signs or symptoms between episodes

BSD

AbbreviationBSD

ExpansionBalloon sinus ostial dilation

Also calledBalloon ostial dilation or balloon sinuplasty

FESS

AbbreviationFESS

ExpansionFunctional endoscopic sinus surgery

Also calledConventional endoscopic sinus surgery or endoscopic sinus surgery

ESS

AbbreviationESS

ExpansionEndoscopic sinus surgery

Clinical useA surgical treatment evaluated for chronic rhinosinusitis after inadequate response to appropriate medical therapy