Sinus Surgeries and Interventions – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare covers balloon sinus ostial dilation (limited to frontal, maxillary, or sphenoid ostia) and/or FESS for medically refractory chronic rhinosinusitis (>12 weeks) or recurrent acute rhinosinusitis (≥4 episodes/year), and FESS for complications (abscess, symptomatic concha bullosa, mucocele, obstructive polyposis, or tumor), but excludes balloon dilation for sinonasal polyps/tumors and considers self‑expanding absorptive devices unproven/not medically necessary. Coverage requires documentation of failed full courses of medical therapy (intranasal ± oral corticosteroids, antibiotics if bacterial infection suspected, and nasal irrigation), a CT obtained after completion of medical therapy within 12 months showing qualifying findings in the sinus(es) to be treated (ostial obstruction, mucosal thickening, opacification, or bony changes) with symptom–CT side correlation, and episode/CT documentation for RARS.

"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 ..."