HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-201-014
Topic:
Balloon Ostial Dilation of the Sinus and Implantable Sinus Stents
Section:
Surgery
Effective Date:
February 18, 2019
Issued Date:
February 18, 2019
Last Revision Date:
December 2018
Annual Review:
November 2018
 
 

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. 

Policy Position

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).  Balloon sinus ostial dilation is considered an inherent part of the FESS procedure, and is not eligible for separate payment:

  • When code 31295 is reported with code 31233, 31256, or 31267, the charges will be combined and processed under code 31233, 31256, or 31267.
  • When code 31296 is reported with code 31276, the charges will be combined and processed under code 31276.
  • When code 31297 is reported with code 31235, 31287, or 31288, the charges will be combined and processed under code 31235, 31287, or 31288.
  • When code 31298 is reported with code 31235, 31276, 31287 or 31288, the charges will be combined and processed under code 31235, 31276, 31287 or 31288.

31233

31235

31241

31253

31256

31257

31259

31267

31276

31287

31288

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.

0406T

0407T

S1090

 

 

 

 



C1726

 

 

 

 

 

 




Covered Diagnosis Codes

 

Balloon Ostial Dilation (31295, 31296, 31297, 31298)

 

J32.1

J32.3

J32.4

J32.8

J32.9

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.



The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

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