Does 31231 require prior authorization?

No, 31231 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 31231?

Medicare facility rate: $54.78. Non-facility rate: $193.39. Work RVU: 1.07.

Verity

`31231`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

1.07

Facility

$54.78

Non-Facility

$193.39

Documentation Required

None specified in the policy.
(Implicit) If submitted despite investigational status, supporting clinical evidence would be required to justify medical necessity, but the CPB provides no explicit documentation checklist or required records.
"History must include specific symptoms and findings obtained by the otolaryngologist. A historical diagnosis labeled 'sinusitis' by the patient or unsubstantiated symptoms alone is not sufficient documentation to establish this as a chronic illness."
"The clinician should confirm a clinical diagnosis of chronic rhinosinusitis (CRS) with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy or computed tomography."

Key Coverage Criteria

None — Aetna considers rhinomanometry, acoustic rhinometry, and optical rhinometry experimental and investigational because of a lack of clinical studies demonstrating that these tests improve clinical outcomes and the effectiveness of these approaches has not been established.
General coverage statement: "Diagnostic nasal/sinus endoscopy, functional endoscopic sinus surgery and turbinectomy ... are considered medically necessary when the associated signs and symptoms or diagnoses are listed in the Coding Information section for ANY of the following: diagnostic nasal/sinus endoscopy; functional endoscopic sinus surgery (FESS); turbinectomy."
Diagnostic nasal/sinus endoscopy — clinical/narrative indications (from General Background / literature): "evaluation of nasal blockage, nasal and sinus infection (rhinosinusitis), osteomyelitis, sinusitis, nasal polyps, mucocele nasal tumors, nasal bleeding, anosmia, hyposmia, parosmia, rhinorrhea, obstructive sleep apnea, choanal atresia, fracture, foreign body, barotrauma and cerebrospinal leak."
Diagnostic nasal/sinus endoscopy — other accepted uses: "evaluation of chronic sinonasal symptoms; assessment of interval response to medical or surgical therapy; monitoring for recurrence of sinusitis and/or nasal polyps; evaluation and management of epistaxis; performance of endoscopically guided cultures; assessment of facial pain suggestive of nasal origin; evaluation of clear rhinorrhea suggestive of cerebrospinal fluid leak; performance of initial diagnosis and interval surveillance for si [...]
FESS — clinical/narrative indications: "chronic sinusitis and recurrent sinusitis refractory to treatment, removal of polyps and mucoceles, excision of tumors, treatment of cerebrospinal fluid leak, barotrauma, orbital decompression, optic nerve decompression, dacryocystorhinostomy, choanal atresia repair, removal of foreign bodies and control of bleeding."
Turbinectomy — clinical/narrative indications: "to clear an obstruction of the turbinate(s), when conservative medical treatment such as nasal steroids, has failed."

3 Active Policies

CIGNA-FESS — Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554)

AETNA-CPB-0700 — Rhinometry and Rhinomanometry

ANTHEM-CG-SURG-57 — CG-SURG-57 Diagnostic Nasal Endoscopy

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31231