HumanaCommercial Clinical Policy

Humana Minimally Invasive Sinus and Eustachian Tube Procedures Form


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

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