UnitedHealthcare Sinus Surgery Coverage Update

Coverage Criteria — When Sinus Surgery (Balloon or FESS) Is Medically Necessary

inv-01: CRS: Indications for Balloon Dilation or FESS

Balloon sinus ostial dilation and/or FESS are proven and medically necessary when ALL of the following are met for Chronic Rhinosinusitis (CRS):

CRS general: Symptoms lasting longer than 12 weeksduration > 12 weeks

Based on policy coverage rationale

Medical therapy: Persistence of symptoms despite recent medical management with full courses of intranasal corticosteroids (and/or oral corticosteroids when appropriate), antibiotic therapy if bacterial infection is suspected, and nasal lavage/irrigation if appropriatetrial of listed medical therapy

Policy requires documentation of completed medical management before imaging and intervention

CT confirmation: Recent CT scan (performed within 12 months) for each sinus to be treated documenting which sinus has disease and extent (percent opacification or Modified Lund-Mackay score) and CT findings including bony remodeling, bony thickening, opacified sinus, ostial obstruction, or mucosal thickeningCT within 12 months

Policy specifies CT obtained after completion of medical management

Symptom concordance: Sinonasal symptoms (e.g., pain, pressure, drainage) are present on the same side as CT findings of rhinosinusitis

Ensures clinical-imaging concordance per policy

Anatomic limitation for balloon dilation: When balloon sinus ostial dilation is used, dilation is limited to the frontal, maxillary, or sphenoid sinuses

Balloon-specific anatomic limitation stated in coverage rationale

inv-02: FESS: Additional Indications

FESS is also medically necessary when ANY of the following CT-confirmed conditions are present:

FESS specific indications: One or more of: complications of sinusitis such as abscess; symptomatic concha bullosa; symptomatic mucocele; polyposis with obstructive symptoms; sinonasal tumor (CT-confirmed)

FESS indications listed in policy when confirmed on CT

inv-03: RARS: Indications for Surgery

Recurrent Acute Rhinosinusitis (RARS) surgical consideration — ALL of the following must be present:

RARS criteria: Four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals; sinonasal symptoms (pain, pressure, drainage) present on same side as CT findings; at least one episode confirmed by CT or nasal endoscopy per guidance

Definition and confirmation requirements from policy and RARS definitions

inv-04: Not Medically Necessary / Experimental

Procedures considered not medically necessary/unproven:

Unproven for balloon dilation: Balloon sinus ostial dilation is unproven and not medically necessary for treating sinonasal polyps or tumors, or for CRS/RARS that do not meet the policy criteria

Policy states BSD is unproven for polyps/tumors and when criteria not met

Unproven for FESS: FESS is not medically necessary for CRS or RARS cases that do not meet the policy criteria

Policy indicates FESS is unproven when criteria are not satisfied

Self-expanding devices: Self-expanding absorptive sinus ostial dilation devices (e.g., SinuSys Vent-OS) are considered unproven and not medically necessary for evaluating or treating sinusitis or other conditions due to insufficient evidence

Policy cites insufficient evidence and pilot/small studies for self-expanding devices

inv-05: Indications supported by consensus and evidence

Covered when ALL of the following are met

Patient selection: Clinical diagnosis of CRS or RARS based on symptoms AND objective documentation by nasal endoscopy documenting sinonasal abnormality or CT demonstrating mucosal thickening or ostial occlusion

Consensus statements (AAO-HNS, ARS) and policy require symptoms plus objective findings

Prior management: Failure of appropriate medical therapy (e.g., saline irrigation and topical intranasal corticosteroids; antibiotics when indicated) before consideration of balloon sinus ostial dilation

Consensus supports prior medical therapy prior to BSD

Procedure setting and use: One of: BSD may be performed as standalone; BSD may be adjunctive to FESS; BSD may be used for limited CRS without polyposis, RARS with ostial occlusion, frontal sinusitis, or persistent disease after prior sinus surgery

AAO-HNS and ARS statements and policy describe appropriate BSD use scenarios

inv-06: Indications for FESS (guideline-derived)

Covered when ALL of the following are met (guidance-based):

ESS coverage typical criteria: 1) Persistent CRS symptoms with objective evidence by endoscopy and/or CT; 2) Failure of appropriate medical treatment (e.g., topical intranasal corticosteroids, saline irrigation; other adjunctive therapy as indicated); 3) Imaging obtained when ESS is considered or planned

Derived from AAO-HNS and allergy/immunology guidance reflected in policy

inv-07: Indications for balloon dilation/XprESS

Covered with specific patient selection:

Balloon sinuplasty / XprESS selection: Uncomplicated CRS patients without severe nasal polyposis who have failed appropriate medical therapy may be considered for sinus dilation (XprESS); XprESS may allow faster recovery and more frequent use of local anesthesia compared with FESS

NICE and EUFOREA position support selective use of XprESS for uncomplicated CRS without severe polyposis

inv-08: Criteria for surgical coverage (ESS or balloon)

Covered when ALL of the following are met documenting failure of medical therapy and objective disease:

Symptom duration: Presence of CRS symptoms (two cardinal symptoms) for >=12 weeks>=12 weeks

ICAR-RS criteria cited in policy

Symptom severity: Preoperative SNOT-22 score >= 20SNOT-22 >=20

ICAR-RS and EUFOREA referenced thresholds

Objective endoscopy: Endoscopic evidence of sinus inflammation and/or purulence

ICAR-RS includes endoscopic inflammation/purulence as MMT criteria

inv-09: Devices with insufficient evidence

Not covered / Experimental when evidence is insufficient:

Self-expanding absorptive ostial dilation: Use of self-expanding absorptive sinus ostial dilation devices is considered investigational/insufficient due to limited data (small sample sizes, lack of comparison groups)

Policy cites lack of robust evidence for these devices

inv-10: Pediatric surgical pathway

Pediatric considerations for coverage:

Adenoidectomy consideration: Adenoidectomy should be strongly considered at least three months prior to pediatric sinus surgery when medical management has failed; evidence comparing pediatric balloon sinuplasty to ESS is indeterminate>=3 months

AAO-HNS pediatric expert consensus recommends adenoidectomy consideration prior to sinus surgery

Balloon sinus ostial dilation and Functional Endoscopic Sinus Surgery (FESS) are explicitly not covered when used to treat sinonasal polyps or tumors, or for cases of CRS or RARS that do not meet the policy’s specified coverage criteria. The policy also states that self‑expanding absorptive sinus ostial dilation devices are considered unproven and not medically necessary for the evaluation or treatment of sinusitis and related conditions due to insufficient evidence of efficacy.

Balloon dilation is not appropriate for patients who lack both sinonasal symptoms and positive CT findings; performing balloon dilation in the absence of concordant symptoms and imaging may be considered inappropriate. The AAO‑HNS consensus also specifies that balloon dilation is not appropriate for management of isolated headache or sleep apnea in patients who do not otherwise meet CRS or RARS diagnostic criteria.

The XprESS multi‑sinus dilation system is supported by NICE for use in selected patients with uncomplicated CRS. NICE recommends that XprESS may be considered when patients do not have severe nasal polyposis, noting comparable effectiveness to FESS with faster recovery and more frequent suitability for local anesthesia in this population.

Self‑expanding absorptive sinus ostial dilation devices (osmotic expansion devices) currently have insufficient evidence to support routine clinical use. Published reports are limited by small sample sizes and lack of comparison groups, and the devices are being studied to determine safety and effectiveness.

Specific self‑expanding absorptive devices (for example, the SinuSys Vent‑OS) are considered unproven and not medically necessary because current evidence does not demonstrate efficacy compared with standard approaches. These devices remain investigational pending higher‑quality comparative data.

Balloon sinus dilation (BSD) has not been shown to benefit patients with barometric pressure‑related sinus headache when CT does not demonstrate mucosal disease. A randomized trial comparing ostial balloon dilation to a nasal cavity placebo procedure found no significant difference in outcomes for patients selected without CT evidence of mucosal thickening.

Imaging is not required for most uncomplicated acute and subacute rhinosinusitis that are managed clinically; however, the ACR recommends obtaining a non‑contrast sinus CT for evaluation of recurrent acute rhinosinusitis prior to surgical intervention or when objective confirmation is needed. CT provides the best preoperative anatomic detail for endoscopic procedures.

Procedures requested without appropriate objective documentation — including absence of a recent CT demonstrating mucosal disease or ostial obstruction, lack of endoscopic findings, or missing documentation of failure of maximal medical therapy — may be considered not medically necessary. The policy requires objective imaging and documentation of failed medical management to support authorization for BSD or FESS.

Coding — Relevant CPT/Device/Scoring Codes and Clinical Thresholds

Endoscopic sinus surgery CPTs (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).
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.

Balloon dilation and additional endoscopic CPTsCPT

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.
31297	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); sphenoid sinus ostium.
31298	Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia.
31299	Unlisted procedure, accessory sinuses.

FDA device product codemixed

LRC	FDA product code for ENT manual surgical instruments (includes balloon dilation devices)

inv-22: Recent CT Scan — within 12 months

DefinitionCT scan performed within 12 months of the planned procedure

Policy useRequired to document which sinus has disease and extent (percent opacification or Modified Lund-Mackay score)

ContextConsidered 'recent' for preoperative planning and prior authorization purposes

inv-23: SNOT-22 — >= 20

Threshold>= 20 (preoperative SNOT-22 score)

RoleUsed to document symptom severity and failure of maximal medical therapy prior to considering ESS or balloon procedures

Provider Actions — Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required for ESS/Balloon Procedures

Prior authorization is required for endoscopic sinus surgery (ESS) and balloon sinus ostial dilation (BSD/Balloon) procedures. Prior authorization must include documentation that imaging and medical therapy requirements below have been met and clearly identify which sinuses will be treated.

Affecting CPT codes: 31240, 31253–31259, 31267, 31276, 31287–31299, 31295–31298 (see Applicable Codes).
Submit recent CT scan images/reports (see Imaging requirements).

Denial Risk

Medical Therapy Required Prior to Surgery; Denial Risk if MMT Not Documented

Providers must document a trial of appropriate medical therapy prior to surgical consideration. Failure to document maximal medical therapy (MMT) is a common denial trigger.

Medical therapy should include intranasal corticosteroids (and/or oral corticosteroids when appropriate), nasal saline irrigation, and when bacterial infection is suspected, a course of antibiotics.

Definitions and Clinical Scoring

inv-44: Chronic Rhinosinusitis (CRS) — inflammatory process >12 weeks with two or more signs/symptoms and objective documentation

DefinitionAn inflammatory process of the paranasal sinuses persisting >12 weeks with two or more signs/symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell) and documented inflammation

Required objective documentationInflammation must be documented by purulent mucus/edema in middle meatus, nasal polyps, and/or radiographic imaging showing sinus inflammation

Clinical implicationDiagnosis requires both persistent symptoms and objective evidence prior to surgical intervention

inv-45: Recurrent Acute Rhinosinusitis (RARS) — Four or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals

DefinitionFour or more episodes per year of acute bacterial rhinosinusitis with distinct symptom-free intervals

Background and Evidence Summary

Chronic rhinosinusitis (CRS) is defined as inflammation of the paranasal sinuses lasting longer than 12 weeks and requiring at least two cardinal signs or symptoms (for example, mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell) plus objective evidence of inflammation by endoscopy or radiographic imaging. FESS is a mucosal‑sparing surgical technique used for CRS refractory to medical therapy; balloon sinus ostial dilation is a less invasive option intended to dilate ostia and may be used alone or adjunctively with FESS.

Revision History

2013-??-??regulatory_clearance

FDA granted 510(k) clearance to the SinuSys Vent-OS Sinus Dilation System for dilation of the maxillary sinus ostia and associated spaces in adults.

2025-03-13regulatory_note_updateLatest

FDA product code LRC (ENT manual surgical instruments, which includes balloon dilation devices) described as 510(k)-exempt; registration and device listing database resources and links updated or referenced as accessed on this date.

OpenPayer

Sinus Surgeries and Interventions (for New Mexico Only)