445 Form

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Medical Policy Ultrasound for the Evaluation of Paranasal Sinuses Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 445

BCBSA Reference Number: 6.01.14A (For Plan internal use only) NCD/LCD: NA Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Ultrasound in the evaluation of paranasal sinuses is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2 Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. HCPCS Codes HCPCS codes: Code Description S9024 Paranasal sinus ultrasound

Description Ultrasound for the evaluation of paranasal sinuses has been proposed as a diagnostic procedure used to confirm the diagnosis of and the presence of sinus fluid in cases of sinusitis in demonstrating mucosal wall thickening, focal soft tissue masses, and complex collections. Ultrasound is nonionizing and non- invasive when compared to the conventional diagnostic alternatives of radiography or sinuscopy for sinus evaluation.

Summary Ultrasonography has been proposed as a convenient office-based alternative with the added advantage of low radiation exposure and a better discriminator between mucosal thickening and fluid retention. However, a review of the literature did not identify any published studies that adequately explored the diagnostic capabilities of ultrasonography in comparison to other imaging options. There is inadequate evidence to demonstrate that ultrasound can improve patient management or outcomes. Policy History Date Action 11/2022 Annual policy review. Policy updated with literature review through October 2022. No references added. Policy statements unchanged. 3/2020 Policy updated with literature review through March 1, 2020, no references added. Policy statements unchanged. 11/2014 Language transferred from Medical Policy 007, Ultrasound. 4/2010 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 4/2009 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. 1/2009 Annual policy review. No changes to policy statements. 4/2007 Reviewed - Medical Policy Group - Cardiology and Pulmonology. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. Haapaniemi J. Comparison of ultrasound and x-ray maxillary sinus findings in school-aged children. Ear Nose Throat J 1997; 76(2):102-6.
2. Savolainen S, Eskelin M, Jousimies-Somer H et al. Radiological findings in the maxillary sinuses of symptomless young men. Acta Otolaryngol Supp 1997; 529:153-7.
3. Vento SI, Ertama LO, Hytonen ML et al. A-mode ultrasound in the diagnosis of chronic polyposis sinusitis. Acta Otolaryngol 1999; 119(8):916-20.
4. American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics 2001: 108(3):798-808.

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5. American Academy of Allergy, Asthma and Immunology. Parameters for the diagnosis and management of sinusitis. Ann Allergy Asthma Immunol 1997; 102(6 pt 2):S107-44.
6. McAlister WH, Parker BR, Kushner DC et al. Sinusitis in the pediatric population. American College
   of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215(suppl):811-8.