Anthem Blue Cross Connecticut CG-SURG-73 Balloon Sinus Ostial Dilation Form

This document addresses the use of balloon sinus ostial dilation for surgery of the sinuses, including for the treatment of sinusitis. These procedures involve insertion of a balloon catheter device into a nasal sinus cavity to open blocked sinus ostia. 

Note: Please see the following related documents for additional information:

• CG-SURG-18 Septoplasty
• CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
• CG-SURG-57 Diagnostic Nasal Endoscopy
• CG-SURG-117 Balloon Dilation of the Eustachian Tubes
• MED.00091 Rhinophototherapy
• SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
• SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Clinical Indications

Note: When Functional Endoscopic Sinus Surgery (FESS) is performed in conjunction with a procedure addressed in this policy, the criteria contained in CG-SURG-24 must be met for the FESS procedure.

Medically Necessary:

The use of balloon sinus ostial dilation is considered medically necessary when all of the following criteria have been met (A, B, C, and D):

1. Treatment is for uncomplicated sinusitis (for example, sinusitis confined to the paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures); and
2. Either of the following:
   1. Four or more documented episodes of acute rhinosinusitis (for example, less than 4 weeks duration) in 1 year; or
   2. Chronic sinusitis (for example, greater than 12 weeks duration);
      and
3. Maximal medical therapy has been attempted, as indicated by all of the following:
   1. Antibiotic therapy; and
   2. Trial of inhaled steroids; and
   3. Nasal lavage; and
   4. Allergy testing (if symptoms are consistent with allergic rhinitis and have not responded to appropriate environmental controls and pharmacotherapy [for example, antihistamines or intranasal corticosteroids or leukotriene antagonists, etc.]);
      and
4. Abnormal findings from diagnostic work-up, as indicated by any one of the following:
   1. Computed tomography (CT) findings suggestive of obstruction or infection for example, but not limited to, air fluid levels, air bubbles, significant mucosal thickening, pansinusitis, or diffuse opacification; or
   2. Nasal endoscopy findings suggestive of significant disease; or
   3. Physical exam findings suggestive of chronic/recurrent disease (for example, mucopurulence, erythema, edema, inflammation).

Not Medically Necessary:

The use of balloon sinus ostial dilation is considered not medically necessary in all other circumstances not stated above, including the following:

1. The criteria above have not been met; or
2. The individual has been diagnosed with presence of sinonasal polyposis; or
3. The procedure is being used to treat the following conditions in the absence of CT-confirmed chronic sinusitis or recurrent acute sinusitis:
   1. Headache; or
   2. Sleep apnea.