Balloon sinus ostial dilation as a stand-alone procedure is considered medically necessary in the sinus being considered for dilation (i.e., frontal, maxillary or sphenoid) for the treatment of chronic sinusitis when ALL of the following criteria are met:
- Presence of two or more of the following signs/symptoms for more than three (3) consecutive months;
- Nasal obstruction; or
- Anterior or posterior mucopurulent (foul) drainage; or
- Facial pain, pressure and/or fullness over the affected sinus; or
- Decreased sense of smell; and
- Evidence of chronic rhinosinusitis on computerized tomography (CT) scan in each of the sinuses being considered for treatment including ANY of the following:
- Mucosal thickening greater than three (3) millimeters; or
- Air fluid levels; or
- Opacification; or
- Nasal polyposis; and
- Failure, intolerance or contraindication of medical management for at least eight (8) consecutive weeks including ALL of the following:
- At least two different full courses of antibiotics; and
- Steroid nasal spray and/or systemic steroids.
Use of a catheter-based inflatable device (balloon sinus ostial dilation) may be considered medically necessary during functional endoscopic sinus surgery (FESS).
Balloon sinus ostial dilation not meeting the criteria as indicated in this policy considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.