Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents

Policy ID: S-201-022

Section: Surgery

Effective Date: July 01, 2018

Revised Date: January 22, 2024

Revision Effective Date: March 04, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Balloon ostial dilation of the sinus involves placing a catheter-based inflatable device in the sinus ostium, inflating the balloon, and dilating the ostium. General anesthesia may be needed to minimize individual's movement.

Criteria

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 (2) 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.

Procedure Codes

31237

31295

31296

31297

31298

31299

The SINUVA Mometasone furoate sinus implant is considered medically necessary for the treatment of recurrent nasal polyps in members 18 years of age and older who have had ethmoid sinus surgery and would otherwise be candidates for revision sinus surgery and have nasal obstruction / congestion symptoms despite use of intranasal steroid irrigations or sprays.

The PROPEL Mometasone Furoate Sinus Implant family of products (PROPEL, PROPEL Mini and PROPEL Contour) is considered medically necessary for maintaining patency following sinus surgery.

Mometasone furoate sinus implant not meeting the criteria as indicated in this policy is 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.

Procedure Codes

J7402

S1091

Outpatient HCPCS (C Code)

C1726

Diagnosis Codes

Covered Diagnosis codes for Procedure Codes 31295, 31296, 31297, 31298

J32.0

J32.1

J32.3

J32.4

J32.8

J.32.9

Professional Statements and Societal Positions Guidelines

American Rhinologic Society and the Academy of Otolaryngology- Head and Neck Surgery 2017

Ostial Balloon Dilation Position Statement

Sinus ostial dilation (e.g., balloon ostial dilation) is a therapeutic option for selected individuals with chronic rhinosinusitis (CRS) and recurrent acute rhinosinusitis (RARS) who have failed appropriate medical therapy. Clinical diagnosis of CRS and RARS should be based on symptoms of sinusitis and supported by nasal endoscopy documenting sinonasal abnormality or mucosal thickening on computed tomography of the paranasal sinuses. This approach may be used alone to dilate an obstructed sinus ostium (frontal, maxillary, or sphenoid) or in conjunction with other instruments (e.g., microdebrider, forceps). The final decision regarding use of techniques or instrumentation for sinus surgery is the responsibility of the attending surgeon.

ND Committee Review

Internal Medical Policy Committee 09/26/2019 HCPCS Update

Internal Medical Policy Committee 5-19-2020

Reversed E/I for propel & added indications for propel

Internal Medical Policy Committee 7-22-2020 Coding update only Internal Medical Policy Committee 3-17-2021 Coding update

Removed C9122, J7401
Added J7402, S1091

Internal Medical Policy Committee 1-20-2022 Revision

Updated with clarifying language.

Internal Medical Policy Committee 9-28-2022 Revision

Updated with clarifying language and
Updated Professional Statements and Societal Positions

Internal Medical Policy Committee 9-12-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Updated References
Removal of specific sinus implants

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-201-021

Section: Surgery

Effective Date: July 01, 2018

Revised Date: August 17, 2022

Revision Effective Date: November 07, 2022

Last Reviewed: September 12, 2023

Archived Date: March 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

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).

Procedure Codes

31237

31295

31296

31297

31298

31299

The PROPEL Mometasone Furoate Sinus Implant family of products (PROPEL, PROPEL Mini and PROPEL Contour) is considered medically necessary for maintaining patency following sinus surgery.

Mometasone furoate sinus implant (e.g. Sinuva, Propel) not meeting the criteria as indicated in this policy is 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.

Procedure Codes

J7402

S1091

Outpatient HCPCS (C Codes)

C1726

Diagnosis Codes

Covered Diagnosis codes for Balloon Ostial Dilation 31295, 31296, 31297, 31298

J32.0

J32.1

J32.3

J32.4

J32.8

J.32.9

Professional Statements and Societal Positions Guidelines

American Rhinologic Society and the Academy of Otolaryngology - Head and Neck Surgery 2017

Ostial Balloon Dilation Position Statement

ND Committee Review

Internal Medical Policy Committee 09/26/2019 HCPCS Update

Internal Medical Policy Committee 5-19-2020

Reversed E/I for propel & added indications for propel

Internal Medical Policy Committee 7-22-2020 Coding update only

Internal Medical Policy Committee 3-17-2021 Coding update

Removed C9122, J7401
Added J7402, S1091

Internal Medical Policy Committee 1-20-2022 Revision

Updated with clarifying language.

Internal Medical Policy Committee 9-28-2022 Revision

Updated with clarifying language and
Updated Professional Statements and Societal Positions

Internal Medical Policy Committee 9-12-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

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