ModifiedUnitedHealthcarePolicy CS138NE.T

Sinus Surgeries and Interventions (for Nebraska Only)

Medical policy governing coverage criteria for balloon sinus ostial dilation, functional endoscopic sinus surgery (FESS), and related sinus interventions for members in Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions (for Nebraska Only)

Policy CodePolicy CS138NE.T

Change TypeDocumentation and administrative updatesmaterial clarification on medical records requirements

Effective DateDec 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record documents history, exam, diagnostic test results (including CT) and is legible and available upon request to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request.

Removed reference link to the guidelines titled Medical Records Documentation Used for Reviews.

Archived previous policy version CS138NE.S.

Reference link to the guidelines titled Medical Records Documentation Used for Reviews was removed.

12 weeksCRS duration

4+ episodes/yrRARS threshold

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.

31295-31299,31240-31288Applicable CPT range

InsufficientSelf-expanding device evidence

93.6%Frontal BSD success

AAO-HNS, ACR, ICAR-RS, EUFOREAGuideline sources

Coverage Criteria for Sinus Procedures

Additional clinical indications (ANY one meets criterion)

Covered when ANY one of the following additional clinical indications is present:

ANY of the following

Complications of sinusitis such as orbital, intracranial, or osseous extension (e.g., abscess, meningitis, osteomyelitis).
Supports FESS per AAO-HNS clinical indicators and practice parameters.
Symptomatic concha bullosa causing obstructive sinonasal symptoms despite medical therapy.
Indication for endoscopic intervention when anatomical variant contributes to obstruction.
Symptomatic mucocele confirmed on imaging and correlated with sinonasal symptoms.
Mucocele may require surgical drainage or removal.
Sinonasal tumor or need for biopsy of sinonasal tissue to rule out neoplasm, granulomatous disease, fungal infection, or ciliary dyskinesia.
Surgical evaluation indicated for diagnosis and management.
Polyposis with obstructive symptoms or suboptimal asthma control despite appropriate medical therapy, including topical intranasal corticosteroids.
FESS indicated when nasal polyps persist after medical management (AAO-HNS; AAAAI/ACAAI/JCAAI).
Recurrent Acute Rhinosinusitis (RARS) meeting definition of ≥4 distinct episodes per year with symptom-free intervals and clinical or CT evidence supporting sinonasal disease.
RARS may be treated with balloon dilation or FESS when criteria met (AAO-HNS consensus; ARS).
Unilateral paranasal sinus opacification consistent with CRS, fungus ball, or benign neoplasm (e.g., inverted papilloma) on CT imaging.
Imaging-directed surgical management recommended (AAO-HNS).
Failure of optimal medical therapy for CRS (medically refractory disease) defined by persistent cardinal symptoms ≥12 weeks and objective evidence of disease on endoscopy or CT.
ESS or balloon dilation may be appropriate per ICAR-RS and AAO-HNS when maximal medical therapy has failed; consider SNOT-22 ≥20 and other guideline thresholds as applicable.
Anatomic defects obstructing sinus outflow tract (e.g., ostiomeatal complex obstruction) that persist despite appropriate medical management and contribute to recurrent or chronic disease.
Surgical correction indicated to restore drainage (AAAAI/ACAAI/JCAAI).
Persistent symptomatic disease in patients who have had prior sinus surgery and have localized ostial obstruction amenable to dilation or adjunctive use of balloon dilation techniques.
AAO-HNS and specialty society statements support role of BSD as adjunct in selected post-operative patients.

Coding and Scoring

Applicable CPT Codes (partial list)CPT

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).

Applicable CPT Codes (continued)CPT

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.
31288	Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus.
31295	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); maxillary sinus ostium, transnasal or via canine fossa.
31296	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal sinus ostium.

1–10 of 13

1/2

Device/Regulatory Codesmixed

LRC	Product code category for ENT manual surgical instruments (includes dilation devices); 510(k)-exempt

inv-21: Recent CT scan — performed within 12 months

Recency requirementCT scan performed within 12 months of the planned procedure.

PurposeCT must document which sinus has disease and extent (percent opacification or Modified Lund-Mackay).

Use caseRecent CT required prior to both balloon sinus ostial dilation and FESS when these procedures are considered or planned.

inv-22: Lund-Mackay CT score — minimum score referenced from a study

Study-derived thresholdMinimum Lund-Mackay CT score of 13.1 was associated with better long-term FESS outcomes in one study.

Scoring context

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization and Required Documentation

Prior authorization may be required for certain procedures and CPT codes. Ensure documentation described below is available in the medical record at the time of review to support medical necessity.

Prior authorization applies to listed procedural codes where plan rules require PA; check member benefits.
If PA is required, submit complete medical record documentation including history, physical exam, imaging, and prior medical therapy.

Documentation Required

Imaging / Objective Confirmation Required Before Dilation

Objective confirmation of disease by nasal endoscopy or CT imaging is required prior to dilation procedures. For balloon sinus ostial dilation, endoscopic or CT evidence of ostial obstruction and mucosal disease in the intended sinus(es) must be documented.

Endoscopy or CT must demonstrate sinonasal inflammation or ostial obstruction on the same side as symptoms.

Clinical Background and Evidence Summary

Background: Chronic Rhinosinusitis (CRS) is inflammation of the paranasal sinuses lasting >12 weeks and requires both characteristic symptoms and objective evidence of inflammation (endoscopy or CT). Functional Endoscopic Sinus Surgery (FESS) is a minimally invasive, mucosal‑sparing surgical approach indicated when symptoms persist despite appropriate medical therapy and when CT or endoscopy documents disease in the sinuses to be addressed. Balloon sinus ostial dilation is an alternative or adjunct technique that dilates sinus ostia and may be appropriate for selected patients with localized or milder disease, but long‑term superiority over FESS is unproven.

Definitions and Abbreviations

inv-45: Chronic Rhinosinusitis (CRS) — definition and criteria

DefinitionChronic Rhinosinusitis (CRS): inflammation of the paranasal sinuses persisting longer than 12 weeks with two or more symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell) and objective evidence of inflammation (polyps, edema, purulent mucus, or radiographic imaging).

Objective confirmationDiagnosing CRS requires documentation of inflammation by purulence or edema in middle meatus/anterior ethmoid, polyps in nasal cavity or middle meatus, and/or radiographic imaging showing sinus inflammation.

Duration thresholdMinimum symptom duration to define CRS is greater than 12 weeks.

inv-46: FESS — Functional Endoscopic Sinus Surgery definition

DefinitionFunctional Endoscopic Sinus Surgery (FESS): a minimally invasive, mucosal-sparing surgical technique used to treat medically refractory CRS with or without polyps, and for RARS.

Policy Revision History

2025-12-01Summary of changesLatest

Added and clarified medical records documentation requirements: the patient’s medical record must fully support medical necessity including relevant history, physical exam, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the record, and made available upon request; archived previous policy version CS138NE.S.

Policy Summary

PayerUnitedHealthcare

PolicySinus Surgeries and Interventions (for Nebraska Only)

Policy CodePolicy CS138NE.T

Change TypeDocumentation and administrative updatesmaterial clarification on medical records requirements

Effective DateDec 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record documents history, exam, diagnostic test results (including CT) and is legible and available upon request to support medical necessity.

SourceLink

On This Page

Lund-Mackay used to quantify sinus opacification pre- and post-operatively in clinical studies.

Interpretation cautionThreshold comes from a single study and should be considered alongside clinical and other objective findings.

inv-23: Objective imaging / symptom thresholds — examples (Lund-Mackay ≥1, SNOT-22 ≥20)

EUFOREA exampleCT Lund-Mackay score ≥1 is cited by EUFOREA as a minimal imaging threshold for offering ESS in uncomplicated CRSsNP.

ICAR-RS/SNOT-22Preoperative SNOT-22 score ≥20 is listed by ICAR-RS as supportive symptom-score threshold for ESS candidacy.

Most actionable thresholdExamples used to support candidacy: Lund-Mackay ≥1 and SNOT-22 ≥20.

Balloon dilation is inappropriate without both sinonasal symptoms and positive CT or endoscopic findings.

Documentation Required

CT Imaging Prior to Surgery (ESS/FESS)

CT of the paranasal sinuses should be obtained when endoscopic sinus surgery (ESS/FESS) is being considered or planned. CT provides essential anatomic detail to guide surgical intervention.

Obtain a non-contrast sinus CT performed within 12 months of the planned procedure.
CT should be obtained after completion of the medical management required by the criteria.
CT must document which sinus has disease and extent of disease, e.g., percent opacification or Modified Lund-Mackay score.

Documentation Required

Imaging and Medical Therapy Documentation

Both imaging (CT and/or endoscopy) and documentation of failure of maximal/appropriate medical therapy are required before surgical procedures for CRS/RARS will be considered medically necessary.

Medical records must document a trial and failure of appropriate medical therapy prior to ESS or dilation when indicated (see examples below).
CT imaging should be obtained after completion of medical therapy to document persistent disease.

Documentation Required

Documentation Must Support Coverage Decisions

The patient's medical record must fully support the medical necessity determination. Documentation should be legible, maintained in the patient's medical record, and made available upon request.

Include relevant medical history, focused physical examination, results of diagnostic tests (CT, endoscopy), and documentation of prior treatments and outcomes.
Failure to provide legible, complete records upon request may result in denial of the request.

Documentation Required

Imaging Prior to ESS or Balloon Dilation

CT scanning of the sinuses is required before balloon dilation and is recommended before ESS; obtain CT imaging when ESS is considered or planned.

CT assists in excluding alternative diagnoses and provides preoperative anatomic detail.
For balloon dilation, CT evidence of ostial occlusion and mucosal thickening in the sinus to be dilated is required.

Denial Risk

Insufficient Documentation Risk

Insufficient or missing documentation increases the risk of denial. Providers must proactively supply the necessary records to demonstrate that clinical criteria are met.

Lack of imaging (CT or endoscopy), absent documentation of prior medical therapy, or illegible records may lead to denial.
If medical records do not substantiate the diagnosis, extent of disease, and prior treatments, coverage will not be approved.

Documentation Required

Medical Therapy Prerequisite

Patients should have persistent sinonasal symptoms despite recent, appropriate medical management prior to consideration of procedural interventions.

Persistence of symptoms for CRS: duration > 12 weeks despite medical therapy.
For RARS: multiple discrete episodes as defined in clinical criteria (e.g., ≥4 episodes/year) with symptom-free intervals.

Documentation Required

Prior Medical Management — Examples

Document prior medical management in the record. Examples of acceptable medical therapy that should be tried and documented include intranasal corticosteroids, antibiotics when bacterial infection is suspected, and nasal saline irrigation.

Intranasal corticosteroids (or oral corticosteroids when appropriate) with dates and response.
Antibiotic therapy if bacterial infection suspected, including duration and response.
Nasal lavage/irrigation use and response.

Documentation Required

Documented Trial of Medical Therapy

Provide clear documentation of the trial and failure of medical therapy (documented trial of medical therapy) prior to approval for ESS or dilation when required by the coverage criteria.

Record dates, medications or interventions tried, duration, and objective/subjective response to therapy.
When applicable, include SNOT-22 scores, endoscopy findings, or other objective measures showing persistent disease.

Denial Risk

Denial for Failure to Meet Criteria

Denial may occur when CRS or RARS cases do not meet the specified clinical criteria, including absence of required imaging evidence or failure to demonstrate appropriate prior medical management.

Procedures (balloon dilation or FESS) are not appropriate in the absence of symptoms with corresponding objective findings on CT or endoscopy.
Balloon dilation is considered not medically necessary for sinonasal polyps or tumors, or when criteria for CRS/RARS are not met.

Documentation Required

Medical Records Availability and Legibility

Providers must ensure medical records are complete and available for review. Records that are illegible, incomplete, or unavailable upon request may result in adverse coverage determinations.

Maintain legible documentation of history, exam, diagnostic tests, and prior treatments in the medical record.
Be prepared to submit records upon request to support authorization or claims review.

Clinical roleUsed when symptoms persist despite medical therapy and objective evidence of disease is present; extent varies (limited to radical) based on disease.

Not device-regulatedFESS is a surgical procedure; devices used during FESS may be regulated but the procedure itself is not an FDA-regulated device.

inv-47: Modified Lund-Mackay; Recent CT — scoring system and recency note

Scoring systemModified Lund-Mackay: per-sinus CT scoring 0–5 by percent opacification (Zinreich modification) with OMC scored 0–2; summed per side to a maximum of 54.

Recency noteA CT is considered recent for policy purposes when performed within 12 months of the planned procedure.

UsageModified Lund-Mackay and OMC/coronal methods are used to quantify disease severity and to document extent of opacification for preoperative planning.

inv-48: RARS — Recurrent Acute Rhinosinusitis definition

DefinitionRecurrent Acute Rhinosinusitis (RARS): four or more episodes per year of acute bacterial rhinosinusitis (ABRS) with distinct symptom-free intervals between episodes.

Episode criteriaEach episode should meet ABRS diagnostic criteria (failure to improve after 10 days or double-worsening) and confirmation of a bacterial episode is preferred when available.

ConfirmationWhen laboratory confirmation of ABRS is not available, examination during an episode is needed to substantiate the diagnosis among the four yearly episodes.

inv-49: RARS — AAO-HNS definition and BSD selection note

AAO-HNS definitionAAO-HNS acknowledges RARS as an appropriate indication for sinus ostial dilation in selected patients and requires symptoms plus objective endoscopic or CT evidence of disease.

Selection noteBSD may be considered for selected RARS patients who meet symptom and imaging criteria; studies reporting improvement are limited by potential selection bias.

Pediatric considerationPediatric recommendations note limited evidence comparing BSD to traditional ESS; adenoidectomy may be considered before sinus surgery in children failing medical management.

inv-50: BSD / BCS / BCD — balloon sinus ostial dilation definition

DefinitionBalloon sinus ostial dilation (BSD/BCS/BCD): use of a balloon catheter to dilate paranasal sinus ostia (frontal, maxillary, sphenoid) as a standalone or adjunct to endoscopic sinus surgery.

Anatomic limitationPer policy, balloon dilation is limited to frontal, maxillary, or sphenoid sinuses (not ethmoid).

Intended useConsidered a minimally invasive option for localized or milder disease, often for patients who have failed appropriate medical therapy.

inv-51: Balloon sinuplasty / ostial dilation — technique description and selection context

Technique descriptionBalloon sinuplasty/ostial dilation dilates sinus ostia with a balloon catheter as a minimally invasive technique to widen natural sinus drainage pathways, which can be performed standalone or adjunctive to FESS.

Selection contextAppropriate for a small subset of patients with medically unresponsive ARS or milder/limited CRS; XprESS may be considered for uncomplicated CRS without severe nasal polyposis and can often be performed under local anesthesia.

Evidence summaryBalloon catheter technology is shown to be safe; long-term superiority over FESS is unproven and patient selection is important.

inv-52: Full-house / limited / radical ESS — extent descriptors

Extent descriptorsLimited ESS: targeted surgery to affected sinus(es); Full-house ESS: multiple sinuses addressed; Radical ESS: extensive procedures sometimes reducing recurrence — extent correlates with symptom improvement in some studies.

Clinical implicationsGreater extent (full-house or radical) may yield greater improvements in patient-reported outcomes and lower recurrence rates in some analyses.

Safety noteAll extents of ESS are reported as relatively safe with no consistent difference in perioperative complications across extents in the cited review.

inv-53: Modified Lund-Mackay / OMC scoring — objective CT-based scoring systems

Modified Lund-MackayCT-based scoring variants (Zinreich/Modified Lund-Mackay) assign per-sinus opacification percentages (0–5) and OMC scored 0–2 to quantify disease severity; used for pre- and post-treatment comparison.

OMC 2D coronal methodA single coronal slice through the ostiomeatal complex (OMC) provides a user-friendly 2D assessment that correlates well with 3D volumetric analysis.

Clinical useThese objective CT-based scoring systems are recommended for documenting extent of disease for surgical planning and outcome assessment.

inv-54: Balloon sinuplasty / sinus ostial dilation — device classification and examples

Regulatory classificationBalloon sinuplasty/sinus ostial dilation devices are classified under FDA product code LRC (instrument, ENT, manual surgical); this product code is 510(k)-exempt.

ExamplesSome devices (e.g., SinuSys Vent-OS) have 510(k) summaries despite the broad LRC classification; manufacturers must register establishments and list devices.

ImplicationFDA classification information is informational and not determinative of coverage decisions.

inv-55: InterQual — third-party criteria tool mention

Tool mentionUnitedHealthcare may use third-party tools such as InterQual criteria to assist in administering health benefits.

PurposeInterQual is referenced as an available resource that may be used alongside clinical judgment in utilization management.

Policy contextInterQual use is informational and does not replace federal, state, or contractual benefit requirements when determining coverage.