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 patient 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 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.

Balloon sinus ostial dilation is considered experimental, investigational or unproven for all other indications and therefore non-covered.

** Balloon sinus ostial dilation is contraindicated in the presence of a mass lesion filling the sinus cavity involved or in the case of inspissated chronic fungal sinusitis.

Use of a catheter-based inflatable device (balloon sinus ostial dilation) may be considered medically necessary during functional endoscopic sinus surgery (FESS).

Procedure Codes

Mometasone furoate sinus implant (e.g.; Sinuva, Propel) is considered medically necessary for the treatment of recurrent nasal polyps in members 18 years of age and olderwho have had ethmoid sinus surgery and would otherwise be candidates forrevision sinus surgery and have nasal obstruction/congestion symptoms despiteuse of intranasal steroid irrigations or sprays.

Mometasone furoate sinus implant (e.g.: Sinuva, Propel) is considered experimental andinvestigational for all other indications because of insufficient evidence in the peer reviewed literature.

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Covered Dx codes for Balloon Ostial Dilation (31295, 31296, 31297, 31298)

Professional Statements and Societal Positions Guidelines

Not Applicable

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

Links

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.