C1726, Catheter, balloon dilatation, non-vascular
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Pre-procedure CT scan of the sinuses is required prior to performing balloon dilation.
- Documentation must include abnormal diagnostic findings: either CT findings (eg, air-fluid levels, air bubbles, mucosal thickening >3 mm, pansinusitis, diffuse opacification) documented by a formal independent radiologist report, or nasal endoscopy showing significant sinus ostial obstruction.
- Prior to dilation, there must be inadequate response to maximal medical therapy including saline nasal irrigation/spray, two or more antibiotic courses or one prolonged course ≥21 days, and a trial of nasal steroids.
- A sinus CT scan is required prior to performing balloon dilation.
Key Coverage Criteria
- I. Diagnostic Esophagogastroduodenoscopy (EGD) in Adults
- EGD for diagnostic purposes for adults aged 18 years or older is consideredmedically necessaryforanyof the following indications:
- Upper abdominal signs or symptoms:Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy (for example, proton pump inhibitors) for 2 months or more;orPersistent vomiting of unknown cause;orNew-onset dyspepsia in individuals 50 years of age or older;orUnexplained dysphagia or odynophagia;orSigns or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea;orPostoperative b [...]
- Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy (for example, proton pump inhibitors) for 2 months or more;or
- Persistent vomiting of unknown cause;or
- New-onset dyspepsia in individuals 50 years of age or older;or
7 Active Policies
ANTHEM-CG-MED-59, CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
ANTHEM-CG-SURG-73, CG-SURG-73 Balloon Sinus Ostial Dilation
BCBSIL-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
BCBSMT-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
BCBSNM-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
Related Codes
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