HumanaCommercial Clinical Policy

Minimally Invasive Sinus and Eustachian Tube Procedures Form

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Balloon Sinus Ostial Dilation

Indications

(16337) Is the dilation limited to the frontal, maxillary, and/or sphenoid sinuses? 
(16338) Is the system used according to the FDA-approved indications for age and sinus cavities? 
(16339) Does documentation of rhinosinusitis define it as greater than 12 consecutive weeks (chronic) or 4 or more occurrences in 1 year (recurrent acute)? 
(16340) Is there documented failure of medical therapy with persistent upper respiratory symptoms despite completion of at least 2 courses of different antibiotics? 
(16341) Has the patient had a trial of at least 6 consecutive weeks using a steroid nasal spray? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

12/14/2023

Last Reviewed

NA

Original Document

  Reference



Minimally Invasive Sinus and Eustachian Tube Procedures

Medical Coverage Policy

Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 04/27/2023
Policy Number: HUM-0309-026

Change Summary: Updated Title, Description, Coverage Limitations, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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