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Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents

Section: Surgery
Effective Date: July 01, 2018
Revised Date: September 26, 2019
Last Reviewed: September 26, 2019

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

31295 31296 31297 31298

The use of implantable steroid-eluting sinus stents (e.g. Propel™) is considered experimental/investigational and, therefore, non-covered for postoperative treatment following endoscopic sinus surgery because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

J7401

Outpatient HCPCS (C Codes)

C1726

Diagnosis Codes

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

J32.0 J32.1 J32.3 J32.4 J32.8 J.32.9

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