31259
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.27
Facility
$397.14
Non-Facility
$397.14
Documentation Required
- CT documentation for each sinus to be treated that identifies which sinus has disease and quantifies extent of disease (percent of opacification or use of an objective scoring system such as the Modified Lund-Mackay Scoring System).
- Recent CT scan of the paranasal sinuses (considered recent if performed within 12 months of the planned procedure); CT must be obtained after completion of the medical management described in the policy.
- Documentation that the member completed full courses of recent medical management prior to surgery: intranasal corticosteroids (and/or oral corticosteroids when appropriate), antibiotic therapy if bacterial infection is suspected, and nasal lavage/irrigation if appropriate.
- Specific CT findings documented for the sinus(es) to be treated: one or more of bony remodeling, bony thickening, opacified sinus, ostial obstruction (outflow tract obstruction), and mucosal thickening.
Key Coverage Criteria
- Balloon sinus ostial dilation and/or Functional Endoscopic Sinus Surgery (FESS) are medically necessary when Chronic Rhinosinusitis (CRS) is present and all of the following are met: lasted longer than 12 weeks; persistence of symptoms despite recent medical management with administration of full courses of all of the following treatments: intranasal corticosteroids (and/or oral corticosteroids when appropriate); antibiotic therapy if bacterial infection is suspected; and nasal lavage/irrigation [...]
- For balloon sinus ostial dilation only: dilation is limited to the frontal, maxillary, or sphenoid sinuses (when performed as indicated above for CRS).
- Recurrent Acute Rhinosinusitis (RARS) is an indication when all of the following are present: four or more episodes per year with distinct symptom-free intervals between episodes; sinonasal symptoms such as pain, pressure, or drainage are present on the same side as CT scan findings of rhinosinusitis; and recent CT scan evidence as specified: for balloon sinus ostial dilation, ostial obstruction (outflow tract obstruction) and mucosal thickening in the sinus to be dilated; for FESS: for maxillar [...]
- FESS is medically necessary when any of the following conditions are confirmed on CT: complications of sinusitis such as abscess; symptomatic concha bullosa; symptomatic mucocele; polyposis with obstructive symptoms (for Chronic Rhinosinusitis with polyps, see CRS criteria above); sinonasal tumor.
- Balloon dilation may be appropriate as an adjunct procedure to FESS in patients with CRS without nasal polyps (per AAO-HNS consensus statements) and can be considered in selected patients with RARS who have failed appropriate medical therapy and meet CT/nasolaryngologic criteria.
- 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."
6 Active Policies
UHC-POL-sinus-surgeries-interventions — Sinus Surgeries and Interventions
UMR-POL-UMR-sinus-surgeries-interventions — Sinus Surgeries and Interventions
SUREST-POL-SUREST-sinus-surgeries-interventions — Sinus Surgeries and Interventions
CIGNA-FESS — Diagnostic Nasal/Sinus Endoscopy, Functional Endoscopic Sinus Surgery (FESS) and Turbinectomy - (0554)
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.