Prior authorization request form Form

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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Guideline Balloon sinuplasty is considered medically necessary when performed along with a functional endoscopic sinus surgery (FESS).
As a stand-alone procedure, balloon sinuplasty is considered medically necessary when the following criteria are met; all:

Rhinosinusitis lasting ≥ 12 weeks
Persistent rhinosinusitis symptoms despite attempted medical management (e.g., nasal lavage, intranasal corticosteroids or antihistamines, antibiotics, if applicable, and/or treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy if applicable)
Recurrent acute sinusitis (RAS) (defined as ≥ 4 episodes per year of acute bacterial rhinosinusitis [ABRS] without signs or symptoms of rhinosinusitis between episodes)
Chronic rhinosinusitis is confirmed by CT/endoscopy scan findings that demonstrate ≥ 1 of the following: a. Mucosal thickening b. Bony remodeling c. Bony thickening d. Obstruction of the ostiomeatal complex e. Mucopurulence f. Edema

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Sinus dilation is for the frontal, maxillary or sphenoid sinuses Limitations and Exclusions Balloon sinus dilation is considered experimental/investigational for all other indications including nasal polyps or tumors. Procedure Codes 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) 31298 Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg balloon dilation)
ICD-10 Diagnoses J01.00 Acute maxillary sinusitis, unspecified J01.01 Acute recurrent maxillary sinusitis J01.10 Acute frontal sinusitis, unspecified J01.11 Acute recurrent frontal sinusitis J01.30 Acute sphenoidal sinusitis, unspecified J01.31 Acute recurrent sphenoidal sinusitis J01.40 Acute pansinusitis, unspecified J01.41 Acute recurrent pansinusitis J01.80 Other acute sinusitis J01.81 Other acute recurrent sinusitis J01.90 Acute sinusitis, unspecified J01.91 Acute recurrent sinusitis, unspecified J32.0 Chronic maxillary sinusitis J32.1 Chronic frontal sinusitis J32.3 Chronic sphenoidal sinusitis J32.4 Chronic pansinusitis J32.8 Other chronic sinusitis J32.9 Chronic sinusitis, unspecified References
U.S. Food and Drug Administration (FDA). 510(K) Summary. Relieva Sinus Balloon Dilation Catheter.

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The American Academy of Otolaryngology-Head and Neck Surgery. Sinus Balloon Catheterization Position Statement. 2007.
American Rhinologic Society (ARS). Ostial Balloon Dilation Position Statement. Revised 3/14/2017. Available at: https://www.american-rhinologic.org/position_https://www.american- rhinologic.org/index.php?option=comcontent&view=article&id=33:ostial-balloon-dilation-position- statement&catid=26:position-statements&Itemid=197dilation. Accessed September 25, 2025.
Abreu CB, Balsalobre L, Pascoto GR, et al. Effectiveness of balloon sinuplasty in patients with chronic rhinosinusitis without polyposis. Braz J Otorhinolaryngol. 2014 Nov-Dec;80(6):470-5.
Bizaki AJ, Taulu R, Numminen J, Rautiainen M. Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomized clinical study. Rhinology. 2014 Dec;52(4):300-5.
Piccirillo, J. F., Payne, S. C., Rosenfeld, R. M., Baroody, F. M., Batra, P. S., DelGaudio, J. M., Corrigan, M. D. (2018). Clinical Consensus Statement: Balloon Dilation of the Sinuses. Otolaryngology–Head and Neck Surgery, 158(2), 203–214.
J Rhinol Allergy. Cutler J, et al. (2013). "Standalone balloon dilation versus sinus surgery for chronic rhinosinusitis: A prospective, multicenter, randomized, controlled trial". Am J RhinolAllergy 27 (5): 416–422.
Specialty matched clinical peer review. Revision History Company(ies) DATE REVISION EmblemHealth Sept. 12, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Mar. 10, 2023 Clarified that balloon sinuplasty is considered medically necessary when performed with FESS EmblemHealth ConnectiCare Sept. 10, 2021 Added endoscopy as a confirmation modality for chronic rhinosinusitis, as it is applicable evaluating to mucopurulence and edema EmblemHealth ConnectiCare Oct. 16, 2020 Corrected recurrent acute sinusitis acronym (changed from ABRS to RAS)
EmblemHealth ConnectiCare Aug. 14, 2020 Added recurrent acute sinusitis (ABRS) as a covered indication Removed endoscopy as an option for evaluating chronic rhinosinusitis (CT scan remains within the policy as the standard) ConnectiCare Jan. 1, 2020
ConnectiCare, Inc. adopts the clinical criteria of its parent corporation EmblemHealth
EmblemHealth Sept. 13, 2019 Added examples of symptoms and management of persistent rhinosinusitis EmblemHealth Sept. 14, 2018
Added endoscopy as accepted chronic rhinosinusitis imaging modality Added mucopurulence and edema to chronic rhinosinusitis findings list

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