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.