Aetna · Clinical coverage policy

Aetna Sinus Surgeries coverage criteria

Aetna CPB 0937 covers sinus surgery procedures as medically necessary only when specific gates are met: endoscopic sinus surgery (ESS) requires a covered diagnosis plus, for chronic/recurrent rhinosinusitis, documented failure of maximal medical therapy (antibiotics if bacterial infection suspected plus 6 weeks of intranasal corticosteroids, longer for children) and objective CT evidence of obstruction and infection; revision ESS and balloon sinus ostial dilation, image-guided ESS, and post-operative debridement each have their own criteria. The bulletin lists many experimental/investigational uses, particularly for balloon ostial dilation (e.g., nasal polyposis grade 2+, fungal sinusitis, tumors, autoimmune or ciliary-dysfunction sinusitis) and sphenopalatine artery ligation for vasomotor rhinitis, and is silent on whether precertification is required.

Policy CPB 0937 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0937

Prior auth

Confirm

Effective

October 5, 2018

This page reflects the coverage criteria captured from Aetna policy CPB 0937 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Sinus Surgeries (CPT 31295), and what gets it denied?

Path
Aetna CPB 0937 covers sinus surgery procedures as medically necessary only when specific gates are met: endoscopic sinus surgery (ESS) requires a covered diagnosis plus, for chronic/recurrent rhinosinusitis, documented failure of maximal medical therapy (antibiotics if bacterial infection suspected plus 6 weeks of intranasal corticosteroids, longer for children) and objective CT evidence of obstruction and infection; revision ESS and balloon sinus ostial dilation, image-guided ESS, and post-operative debridement each have their own criteria. The bulletin lists many experimental/investigational uses, particularly for balloon ostial dilation (e.g., nasal polyposis grade 2+, fungal sinusitis, tumors, autoimmune or ciliary-dysfunction sinusitis) and sphenopalatine artery ligation for vasomotor rhinitis, and is silent on whether precertification is required. Coverage criteria include: Endoscopic sinus surgery (ESS) is medically necessary for ANY ONE of indications #1-#17 below.; ESS medically necessary for: Allergic fungal rhino-sinusitis with objective evidence of disease by CT imaging (abnormal CT findings required).; ESS medically necessary for: Antro-choanal polyp documented by CT imaging.; ESS medically necessary for: Cerebrospinal fluid (CSF) rhinorrhea or conditions with a skull base defect.; ESS medically necessary for: Chronic rhino-sinusitis with nasal polyps (CRSwNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.; ESS medically necessary for: Chronic rhino-sinusitis without nasal polyps (CRSsNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.; ESS medically necessary for: Complications of sinusitis, including abscess (brain and sub-periosteal) and extension to adjacent structures (orbit, skull base).; ESS medically necessary for: Endonasal endoscopic hypophysectomy for pituitary adenoma.; ESS medically necessary for: Endoscopic orbital decompression for Graves ophthalmopathy, with or without optic nerve decompression.; ESS medically necessary for: Endoscopic partial ethmoidectomy for dacryocystorhinostomy.; ESS medically necessary for: Para-nasal sinus mucocele documented by CT scan (EXCLUDING benign, asymptomatic mucus retention cysts).; ESS medically necessary for: Recurrent acute rhino-sinusitis (RARS) when ALL of the following are met: (a) 4 or more documented episodes of acute rhinosinusitis within 12 continuous months with complete resolution of symptoms between episodes; AND (b) episodes have recurred despite maximal medical treatment (intranasal corticosteroids during acute episodes, plus antibiotics if bacterial infection suspected); AND (c) EITHER objective evidence of outflow tract obstruction (not just narrowing/stenosis) or sinus infection by CT imaging, OR evidence of rhinosinusitis by endoscopy during at least one acute episode.; ESS medically necessary for: Recurrent sinus barotrauma when conservative management (oral decongestants, analgesics, antibiotics if purulent nasal discharge present) has failed.; ESS medically necessary for: Silent sinus syndrome when endonasal endoscopic examination AND orbital/paranasal CT scans have confirmed the diagnosis.; ESS medically necessary for: Sino-nasal polyposis with nasal airway obstruction OR sub-optimal asthma control (FEV1 less than 80%) despite maximal medical treatment (antibiotics if bacterial infection suspected, and intra-nasal corticosteroids).; ESS medically necessary for: Suspected or known sino-nasal benign or malignant tumor, including squamous cell, adenoid cystic, adenocarcinoma, inverted papilloma.; ESS medically necessary for: Uncomplicated chronic rhinosinusitis in children up to 12 years of age with evidence of disease by CT imaging IF the child failed maximal medical therapy (meet ALL: 8 weeks intra-nasal corticosteroids AND 3 weeks antibiotics) AND failed adenoidectomy (adenoidectomy must precede ESS consideration).; ESS medically necessary for: Unilateral pansinus opacification (symptomatic or asymptomatic) consistent with CRSsNP, CRSwNP, fungus ball, or neoplasm (e.g., sino-nasal inverted papilloma). NOTE: a trial of conservative treatment is NOT required for unilateral pansinus opacification.; CT imaging requirement for ESS coverage: abnormal CT findings must include evidence of obstruction AND infection; CT documentation must include (ONE of) a detailed description of abnormal findings in each sinus, OR quantification of extent of disease as percent opacification, OR use of the Modified Lund-Mackay Scoring System; CT must be recent (within 12 months) and taken at completion of therapy.; Revision ESS is medically necessary when ALL of the following are met: at least 12 weeks have passed since the previous ESS; chronic rhino-sinusitis present for at least 12 continuous weeks; failure of at least one 5-7 day course of antibiotics since the previous ESS; AND persistent objective evidence of sinus disease by CT imaging.; Balloon sinus ostial dilation (balloon sinuplasty) is medically necessary for treatment of uncomplicated sinusitis WITHOUT nasal polyposis (sinusitis confined to paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures), or presence of fungal debris, when AAO-HNS consensus criteria are met (Appendix Table 1). NOTE: when used with FESS in the same sinus cavity it is considered an integral part of the primary procedure.; Image-guided ESS is medically necessary for ANY of the following: benign and malignant sino-nasal neoplasms (e.g., sino-nasal inverted papilloma); CSF rhinorrhea or conditions with skull base defect; disease abutting the skull base, orbit, optic nerve, or carotid artery; distorted sinus anatomy of developmental, post-operative, or traumatic origin (e.g., hypoplastic maxillary sinus, orbital fat and medial rectus herniation, scarring or absence of normal surgical landmarks from prior sinus surgery); sino-nasal polyposis with nasal airway obstruction or sub-optimal asthma control; revision sinus surgery; OR sinus disease involving the frontal, posterior ethmoid, and sphenoid sinuses.; Post-operative nasal endoscopy with debridement is medically necessary up to 3 times within 6 weeks following sinus surgery.; Additional post-operative nasal endoscopy with debridement (beyond 3, or outside the 6-week window) may be allowed if records document ANY of the following: persistent crusting; recurrent polyps; allergic mucin; retained fungal material; synechiae obstructing sinus ostia; OR a lateralized middle turbinate with ostial obstruction.; Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is medically necessary when abnormal findings on CT scanning indicate the need for an invasive diagnostic procedure (e.g., tumor/mass plus multiple sinus symptoms such as nasal obstruction, anterior or posterior mucopurulent drainage, facial pain, pressure, headache with other causes ruled out, fullness over the affected sinus, or decreased sense of smell).. Applies to 14 codes: 31295, 31296, 31297, 31298, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Dates of each episode of acute rhinosinusitis and the types and durations of treatments for each episode should be documented in the medical record (for RARS).; CT report documentation must include (ONE of): a detailed description of the abnormal findings in each sinus, OR quantification of the extent of disease as a percent of opacification, OR use of a scale such as the Modified Lund-Mackay Scoring System.; Abnormal CT findings must document evidence of obstruction and infection.; CT scan must be recent (within 12 months) and taken at the completion of therapy; imaging must be performed within the past year, OR after onset of the current constellation of symptoms, OR after relevant surgical procedures, whichever is sooner.; Electronic submission of CT scan images may be required.; Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram); if the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there must be a written addendum to the official report indicating agreement or disagreement (reading by a radiologist required to validate any changes).; For additional post-operative nasal endoscopy with debridement, records must be provided documenting at least one of: persistent crusting, recurrent polyps, allergic mucin, retained fungal material, synechiae obstructing sinus ostia, or a lateralized middle turbinate with ostial obstruction.; For diagnostic endoscopy with puncture, documentation of the abnormal CT findings and the clinical presentation (symptoms present and physical findings) is required.
Trap
Policy exclusions and limitations: Balloon ostial dilation is experimental, investigational, or unproven for: Antro-choanal polyp.; Balloon ostial dilation is experimental, investigational, or unproven for: Bony dysplasia (including but not limited to fibrous dysplasia, Paget's disease).; Balloon ostial dilation is experimental, investigational, or unproven for: Extensive fungal sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: History of a failed balloon procedure in the sinus to be treated.; Balloon ostial dilation is experimental, investigational, or unproven for: Isolated ethmoid sinus disease.; Balloon ostial dilation is experimental, investigational, or unproven for: Mucocele causing sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: Nasal polyposis (grade 2 or greater).; Balloon ostial dilation is experimental, investigational, or unproven for: Recurrent sinus barotrauma.; Balloon ostial dilation is experimental, investigational, or unproven for: Repeat balloon procedure in any of the sinuses.; Balloon ostial dilation is experimental, investigational, or unproven for: Samter's triad (aspirin sensitivity).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to autoimmune or connective tissue disorders (e.g., sarcoidosis, granulomatosis with polyangiitis).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to ciliary dysfunction (e.g., cystic fibrosis, Kartagener's syndrome).; Balloon ostial dilation is experimental, investigational, or unproven for: Suppurative or non-suppurative complications of sinusitis, including extension to the orbit or CNS.; Balloon ostial dilation is experimental, investigational, or unproven for: Suspected or known sino-nasal benign or malignant tumor.; Balloon ostial dilation is experimental, investigational, or unproven for: Unilateral pansinus opacification. (This balloon E/I list is stated as not all-inclusive.); Sphenopalatine artery ligation with post-ganglionic posterior nasal nerve ablation is experimental, investigational, or unproven for the treatment of vasomotor rhinitis.; Endoscopic sinus surgery (ESS) is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Image-guided ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Revision ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not meeting the specified selection criteria).; Post-operative nasal endoscopy with debridement is not medically necessary after nasal surgery (e.g., septoplasty, turbinectomy).; Post-operative nasal endoscopy with debridement is not medically necessary after balloon sinuplasty.; Additional post-operative debridement outside the 6-week post-operative period is not medically necessary unless the clinical circumstances are well-documented.; Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is not medically necessary when the stated criteria are not met (i.e., when abnormal CT findings do not indicate the need for an invasive procedure).; Diagnostic endoscopy with puncture is not medically necessary for isolated symptoms of headache or sleep apnea that do not meet the criteria for sinusitis.; Para-nasal sinus mucocele coverage excludes benign, asymptomatic mucus retention cysts (not covered as a mucocele indication). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0937 — Sinus Surgeries

Coverage criteria

  • Endoscopic sinus surgery (ESS) is medically necessary for ANY ONE of indications #1-#17 below.
  • ESS medically necessary for: Allergic fungal rhino-sinusitis with objective evidence of disease by CT imaging (abnormal CT findings required).
  • ESS medically necessary for: Antro-choanal polyp documented by CT imaging.
  • ESS medically necessary for: Cerebrospinal fluid (CSF) rhinorrhea or conditions with a skull base defect.
  • ESS medically necessary for: Chronic rhino-sinusitis with nasal polyps (CRSwNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.
  • ESS medically necessary for: Chronic rhino-sinusitis without nasal polyps (CRSsNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.
  • ESS medically necessary for: Complications of sinusitis, including abscess (brain and sub-periosteal) and extension to adjacent structures (orbit, skull base).
  • ESS medically necessary for: Endonasal endoscopic hypophysectomy for pituitary adenoma.
  • ESS medically necessary for: Endoscopic orbital decompression for Graves ophthalmopathy, with or without optic nerve decompression.
  • ESS medically necessary for: Endoscopic partial ethmoidectomy for dacryocystorhinostomy.
  • ESS medically necessary for: Para-nasal sinus mucocele documented by CT scan (EXCLUDING benign, asymptomatic mucus retention cysts).
  • ESS medically necessary for: Recurrent acute rhino-sinusitis (RARS) when ALL of the following are met: (a) 4 or more documented episodes of acute rhinosinusitis within 12 continuous months with complete resolution of symptoms between episodes; AND (b) episodes have recurred despite maximal medical treatment (intranasal corticosteroids during acute episodes, plus antibiotics if bacterial infection suspected); AND (c) EITHER objective evidence of outflow tract obstruction (not just narrowing/stenosis) or sinus infection by CT imaging, OR evidence of rhinosinusitis by endoscopy during at least one acute episode.
  • ESS medically necessary for: Recurrent sinus barotrauma when conservative management (oral decongestants, analgesics, antibiotics if purulent nasal discharge present) has failed.
  • ESS medically necessary for: Silent sinus syndrome when endonasal endoscopic examination AND orbital/paranasal CT scans have confirmed the diagnosis.
  • ESS medically necessary for: Sino-nasal polyposis with nasal airway obstruction OR sub-optimal asthma control (FEV1 less than 80%) despite maximal medical treatment (antibiotics if bacterial infection suspected, and intra-nasal corticosteroids).
  • ESS medically necessary for: Suspected or known sino-nasal benign or malignant tumor, including squamous cell, adenoid cystic, adenocarcinoma, inverted papilloma.
  • ESS medically necessary for: Uncomplicated chronic rhinosinusitis in children up to 12 years of age with evidence of disease by CT imaging IF the child failed maximal medical therapy (meet ALL: 8 weeks intra-nasal corticosteroids AND 3 weeks antibiotics) AND failed adenoidectomy (adenoidectomy must precede ESS consideration).
  • ESS medically necessary for: Unilateral pansinus opacification (symptomatic or asymptomatic) consistent with CRSsNP, CRSwNP, fungus ball, or neoplasm (e.g., sino-nasal inverted papilloma). NOTE: a trial of conservative treatment is NOT required for unilateral pansinus opacification.
  • CT imaging requirement for ESS coverage: abnormal CT findings must include evidence of obstruction AND infection; CT documentation must include (ONE of) a detailed description of abnormal findings in each sinus, OR quantification of extent of disease as percent opacification, OR use of the Modified Lund-Mackay Scoring System; CT must be recent (within 12 months) and taken at completion of therapy.
  • Revision ESS is medically necessary when ALL of the following are met: at least 12 weeks have passed since the previous ESS; chronic rhino-sinusitis present for at least 12 continuous weeks; failure of at least one 5-7 day course of antibiotics since the previous ESS; AND persistent objective evidence of sinus disease by CT imaging.
  • Balloon sinus ostial dilation (balloon sinuplasty) is medically necessary for treatment of uncomplicated sinusitis WITHOUT nasal polyposis (sinusitis confined to paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures), or presence of fungal debris, when AAO-HNS consensus criteria are met (Appendix Table 1). NOTE: when used with FESS in the same sinus cavity it is considered an integral part of the primary procedure.
  • Image-guided ESS is medically necessary for ANY of the following: benign and malignant sino-nasal neoplasms (e.g., sino-nasal inverted papilloma); CSF rhinorrhea or conditions with skull base defect; disease abutting the skull base, orbit, optic nerve, or carotid artery; distorted sinus anatomy of developmental, post-operative, or traumatic origin (e.g., hypoplastic maxillary sinus, orbital fat and medial rectus herniation, scarring or absence of normal surgical landmarks from prior sinus surgery); sino-nasal polyposis with nasal airway obstruction or sub-optimal asthma control; revision sinus surgery; OR sinus disease involving the frontal, posterior ethmoid, and sphenoid sinuses.
  • Post-operative nasal endoscopy with debridement is medically necessary up to 3 times within 6 weeks following sinus surgery.
  • Additional post-operative nasal endoscopy with debridement (beyond 3, or outside the 6-week window) may be allowed if records document ANY of the following: persistent crusting; recurrent polyps; allergic mucin; retained fungal material; synechiae obstructing sinus ostia; OR a lateralized middle turbinate with ostial obstruction.
  • Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is medically necessary when abnormal findings on CT scanning indicate the need for an invasive diagnostic procedure (e.g., tumor/mass plus multiple sinus symptoms such as nasal obstruction, anterior or posterior mucopurulent drainage, facial pain, pressure, headache with other causes ruled out, fullness over the affected sinus, or decreased sense of smell).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Dates of each episode of acute rhinosinusitis and the types and durations of treatments for each episode should be documented in the medical record (for RARS).
  • CT report documentation must include (ONE of): a detailed description of the abnormal findings in each sinus, OR quantification of the extent of disease as a percent of opacification, OR use of a scale such as the Modified Lund-Mackay Scoring System.
  • Abnormal CT findings must document evidence of obstruction and infection.
  • CT scan must be recent (within 12 months) and taken at the completion of therapy; imaging must be performed within the past year, OR after onset of the current constellation of symptoms, OR after relevant surgical procedures, whichever is sooner.
  • Electronic submission of CT scan images may be required.
  • Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram); if the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there must be a written addendum to the official report indicating agreement or disagreement (reading by a radiologist required to validate any changes).
  • For additional post-operative nasal endoscopy with debridement, records must be provided documenting at least one of: persistent crusting, recurrent polyps, allergic mucin, retained fungal material, synechiae obstructing sinus ostia, or a lateralized middle turbinate with ostial obstruction.
  • For diagnostic endoscopy with puncture, documentation of the abnormal CT findings and the clinical presentation (symptoms present and physical findings) is required.

Frequently asked questions

When does Aetna cover Sinus Surgeries (CPT 31295), and what gets it denied?
Aetna CPB 0937 covers sinus surgery procedures as medically necessary only when specific gates are met: endoscopic sinus surgery (ESS) requires a covered diagnosis plus, for chronic/recurrent rhinosinusitis, documented failure of maximal medical therapy (antibiotics if bacterial infection suspected plus 6 weeks of intranasal corticosteroids, longer for children) and objective CT evidence of obstruction and infection; revision ESS and balloon sinus ostial dilation, image-guided ESS, and post-operative debridement each have their own criteria. The bulletin lists many experimental/investigational uses, particularly for balloon ostial dilation (e.g., nasal polyposis grade 2+, fungal sinusitis, tumors, autoimmune or ciliary-dysfunction sinusitis) and sphenopalatine artery ligation for vasomotor rhinitis, and is silent on whether precertification is required. Coverage criteria include: Endoscopic sinus surgery (ESS) is medically necessary for ANY ONE of indications #1-#17 below.; ESS medically necessary for: Allergic fungal rhino-sinusitis with objective evidence of disease by CT imaging (abnormal CT findings required).; ESS medically necessary for: Antro-choanal polyp documented by CT imaging.; ESS medically necessary for: Cerebrospinal fluid (CSF) rhinorrhea or conditions with a skull base defect.; ESS medically necessary for: Chronic rhino-sinusitis with nasal polyps (CRSwNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.; ESS medically necessary for: Chronic rhino-sinusitis without nasal polyps (CRSsNP) longer than 12 continuous weeks with persistent symptoms that have failed maximal medical treatment (meet ALL: minimum 5-7 days antibiotics IF bacterial infection suspected, AND 6 weeks intra-nasal corticosteroids) AND objective evidence of disease by CT imaging.; ESS medically necessary for: Complications of sinusitis, including abscess (brain and sub-periosteal) and extension to adjacent structures (orbit, skull base).; ESS medically necessary for: Endonasal endoscopic hypophysectomy for pituitary adenoma.; ESS medically necessary for: Endoscopic orbital decompression for Graves ophthalmopathy, with or without optic nerve decompression.; ESS medically necessary for: Endoscopic partial ethmoidectomy for dacryocystorhinostomy.; ESS medically necessary for: Para-nasal sinus mucocele documented by CT scan (EXCLUDING benign, asymptomatic mucus retention cysts).; ESS medically necessary for: Recurrent acute rhino-sinusitis (RARS) when ALL of the following are met: (a) 4 or more documented episodes of acute rhinosinusitis within 12 continuous months with complete resolution of symptoms between episodes; AND (b) episodes have recurred despite maximal medical treatment (intranasal corticosteroids during acute episodes, plus antibiotics if bacterial infection suspected); AND (c) EITHER objective evidence of outflow tract obstruction (not just narrowing/stenosis) or sinus infection by CT imaging, OR evidence of rhinosinusitis by endoscopy during at least one acute episode.; ESS medically necessary for: Recurrent sinus barotrauma when conservative management (oral decongestants, analgesics, antibiotics if purulent nasal discharge present) has failed.; ESS medically necessary for: Silent sinus syndrome when endonasal endoscopic examination AND orbital/paranasal CT scans have confirmed the diagnosis.; ESS medically necessary for: Sino-nasal polyposis with nasal airway obstruction OR sub-optimal asthma control (FEV1 less than 80%) despite maximal medical treatment (antibiotics if bacterial infection suspected, and intra-nasal corticosteroids).; ESS medically necessary for: Suspected or known sino-nasal benign or malignant tumor, including squamous cell, adenoid cystic, adenocarcinoma, inverted papilloma.; ESS medically necessary for: Uncomplicated chronic rhinosinusitis in children up to 12 years of age with evidence of disease by CT imaging IF the child failed maximal medical therapy (meet ALL: 8 weeks intra-nasal corticosteroids AND 3 weeks antibiotics) AND failed adenoidectomy (adenoidectomy must precede ESS consideration).; ESS medically necessary for: Unilateral pansinus opacification (symptomatic or asymptomatic) consistent with CRSsNP, CRSwNP, fungus ball, or neoplasm (e.g., sino-nasal inverted papilloma). NOTE: a trial of conservative treatment is NOT required for unilateral pansinus opacification.; CT imaging requirement for ESS coverage: abnormal CT findings must include evidence of obstruction AND infection; CT documentation must include (ONE of) a detailed description of abnormal findings in each sinus, OR quantification of extent of disease as percent opacification, OR use of the Modified Lund-Mackay Scoring System; CT must be recent (within 12 months) and taken at completion of therapy.; Revision ESS is medically necessary when ALL of the following are met: at least 12 weeks have passed since the previous ESS; chronic rhino-sinusitis present for at least 12 continuous weeks; failure of at least one 5-7 day course of antibiotics since the previous ESS; AND persistent objective evidence of sinus disease by CT imaging.; Balloon sinus ostial dilation (balloon sinuplasty) is medically necessary for treatment of uncomplicated sinusitis WITHOUT nasal polyposis (sinusitis confined to paranasal sinuses without adjacent involvement of neurologic, soft tissue, or bony structures), or presence of fungal debris, when AAO-HNS consensus criteria are met (Appendix Table 1). NOTE: when used with FESS in the same sinus cavity it is considered an integral part of the primary procedure.; Image-guided ESS is medically necessary for ANY of the following: benign and malignant sino-nasal neoplasms (e.g., sino-nasal inverted papilloma); CSF rhinorrhea or conditions with skull base defect; disease abutting the skull base, orbit, optic nerve, or carotid artery; distorted sinus anatomy of developmental, post-operative, or traumatic origin (e.g., hypoplastic maxillary sinus, orbital fat and medial rectus herniation, scarring or absence of normal surgical landmarks from prior sinus surgery); sino-nasal polyposis with nasal airway obstruction or sub-optimal asthma control; revision sinus surgery; OR sinus disease involving the frontal, posterior ethmoid, and sphenoid sinuses.; Post-operative nasal endoscopy with debridement is medically necessary up to 3 times within 6 weeks following sinus surgery.; Additional post-operative nasal endoscopy with debridement (beyond 3, or outside the 6-week window) may be allowed if records document ANY of the following: persistent crusting; recurrent polyps; allergic mucin; retained fungal material; synechiae obstructing sinus ostia; OR a lateralized middle turbinate with ostial obstruction.; Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is medically necessary when abnormal findings on CT scanning indicate the need for an invasive diagnostic procedure (e.g., tumor/mass plus multiple sinus symptoms such as nasal obstruction, anterior or posterior mucopurulent drainage, facial pain, pressure, headache with other causes ruled out, fullness over the affected sinus, or decreased sense of smell).. Applies to 14 codes: 31295, 31296, 31297, 31298, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Dates of each episode of acute rhinosinusitis and the types and durations of treatments for each episode should be documented in the medical record (for RARS).; CT report documentation must include (ONE of): a detailed description of the abnormal findings in each sinus, OR quantification of the extent of disease as a percent of opacification, OR use of a scale such as the Modified Lund-Mackay Scoring System.; Abnormal CT findings must document evidence of obstruction and infection.; CT scan must be recent (within 12 months) and taken at the completion of therapy; imaging must be performed within the past year, OR after onset of the current constellation of symptoms, OR after relevant surgical procedures, whichever is sooner.; Electronic submission of CT scan images may be required.; Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram); if the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there must be a written addendum to the official report indicating agreement or disagreement (reading by a radiologist required to validate any changes).; For additional post-operative nasal endoscopy with debridement, records must be provided documenting at least one of: persistent crusting, recurrent polyps, allergic mucin, retained fungal material, synechiae obstructing sinus ostia, or a lateralized middle turbinate with ostial obstruction.; For diagnostic endoscopy with puncture, documentation of the abnormal CT findings and the clinical presentation (symptoms present and physical findings) is required. Policy exclusions and limitations: Balloon ostial dilation is experimental, investigational, or unproven for: Antro-choanal polyp.; Balloon ostial dilation is experimental, investigational, or unproven for: Bony dysplasia (including but not limited to fibrous dysplasia, Paget's disease).; Balloon ostial dilation is experimental, investigational, or unproven for: Extensive fungal sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: History of a failed balloon procedure in the sinus to be treated.; Balloon ostial dilation is experimental, investigational, or unproven for: Isolated ethmoid sinus disease.; Balloon ostial dilation is experimental, investigational, or unproven for: Mucocele causing sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: Nasal polyposis (grade 2 or greater).; Balloon ostial dilation is experimental, investigational, or unproven for: Recurrent sinus barotrauma.; Balloon ostial dilation is experimental, investigational, or unproven for: Repeat balloon procedure in any of the sinuses.; Balloon ostial dilation is experimental, investigational, or unproven for: Samter's triad (aspirin sensitivity).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to autoimmune or connective tissue disorders (e.g., sarcoidosis, granulomatosis with polyangiitis).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to ciliary dysfunction (e.g., cystic fibrosis, Kartagener's syndrome).; Balloon ostial dilation is experimental, investigational, or unproven for: Suppurative or non-suppurative complications of sinusitis, including extension to the orbit or CNS.; Balloon ostial dilation is experimental, investigational, or unproven for: Suspected or known sino-nasal benign or malignant tumor.; Balloon ostial dilation is experimental, investigational, or unproven for: Unilateral pansinus opacification. (This balloon E/I list is stated as not all-inclusive.); Sphenopalatine artery ligation with post-ganglionic posterior nasal nerve ablation is experimental, investigational, or unproven for the treatment of vasomotor rhinitis.; Endoscopic sinus surgery (ESS) is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Image-guided ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Revision ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not meeting the specified selection criteria).; Post-operative nasal endoscopy with debridement is not medically necessary after nasal surgery (e.g., septoplasty, turbinectomy).; Post-operative nasal endoscopy with debridement is not medically necessary after balloon sinuplasty.; Additional post-operative debridement outside the 6-week post-operative period is not medically necessary unless the clinical circumstances are well-documented.; Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is not medically necessary when the stated criteria are not met (i.e., when abnormal CT findings do not indicate the need for an invasive procedure).; Diagnostic endoscopy with puncture is not medically necessary for isolated symptoms of headache or sleep apnea that do not meet the criteria for sinusitis.; Para-nasal sinus mucocele coverage excludes benign, asymptomatic mucus retention cysts (not covered as a mucocele indication). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Sinus Surgeries?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Dates of each episode of acute rhinosinusitis and the types and durations of treatments for each episode should be documented in the medical record (for RARS).; CT report documentation must include (ONE of): a detailed description of the abnormal findings in each sinus, OR quantification of the extent of disease as a percent of opacification, OR use of a scale such as the Modified Lund-Mackay Scoring System.; Abnormal CT findings must document evidence of obstruction and infection.; CT scan must be recent (within 12 months) and taken at the completion of therapy; imaging must be performed within the past year, OR after onset of the current constellation of symptoms, OR after relevant surgical procedures, whichever is sooner.; Electronic submission of CT scan images may be required.; Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram); if the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there must be a written addendum to the official report indicating agreement or disagreement (reading by a radiologist required to validate any changes).; For additional post-operative nasal endoscopy with debridement, records must be provided documenting at least one of: persistent crusting, recurrent polyps, allergic mucin, retained fungal material, synechiae obstructing sinus ostia, or a lateralized middle turbinate with ostial obstruction.; For diagnostic endoscopy with puncture, documentation of the abnormal CT findings and the clinical presentation (symptoms present and physical findings) is required.
What does Aetna exclude for Sinus Surgeries?
Policy exclusions and limitations: Balloon ostial dilation is experimental, investigational, or unproven for: Antro-choanal polyp.; Balloon ostial dilation is experimental, investigational, or unproven for: Bony dysplasia (including but not limited to fibrous dysplasia, Paget's disease).; Balloon ostial dilation is experimental, investigational, or unproven for: Extensive fungal sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: History of a failed balloon procedure in the sinus to be treated.; Balloon ostial dilation is experimental, investigational, or unproven for: Isolated ethmoid sinus disease.; Balloon ostial dilation is experimental, investigational, or unproven for: Mucocele causing sinusitis.; Balloon ostial dilation is experimental, investigational, or unproven for: Nasal polyposis (grade 2 or greater).; Balloon ostial dilation is experimental, investigational, or unproven for: Recurrent sinus barotrauma.; Balloon ostial dilation is experimental, investigational, or unproven for: Repeat balloon procedure in any of the sinuses.; Balloon ostial dilation is experimental, investigational, or unproven for: Samter's triad (aspirin sensitivity).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to autoimmune or connective tissue disorders (e.g., sarcoidosis, granulomatosis with polyangiitis).; Balloon ostial dilation is experimental, investigational, or unproven for: Severe sinusitis secondary to ciliary dysfunction (e.g., cystic fibrosis, Kartagener's syndrome).; Balloon ostial dilation is experimental, investigational, or unproven for: Suppurative or non-suppurative complications of sinusitis, including extension to the orbit or CNS.; Balloon ostial dilation is experimental, investigational, or unproven for: Suspected or known sino-nasal benign or malignant tumor.; Balloon ostial dilation is experimental, investigational, or unproven for: Unilateral pansinus opacification. (This balloon E/I list is stated as not all-inclusive.); Sphenopalatine artery ligation with post-ganglionic posterior nasal nerve ablation is experimental, investigational, or unproven for the treatment of vasomotor rhinitis.; Endoscopic sinus surgery (ESS) is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Image-guided ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not listed as medically necessary).; Revision ESS is experimental, investigational, or unproven for all other indications (i.e., any indication not meeting the specified selection criteria).; Post-operative nasal endoscopy with debridement is not medically necessary after nasal surgery (e.g., septoplasty, turbinectomy).; Post-operative nasal endoscopy with debridement is not medically necessary after balloon sinuplasty.; Additional post-operative debridement outside the 6-week post-operative period is not medically necessary unless the clinical circumstances are well-documented.; Diagnostic endoscopy with puncture of the sphenoid/maxillary sinuses is not medically necessary when the stated criteria are not met (i.e., when abnormal CT findings do not indicate the need for an invasive procedure).; Diagnostic endoscopy with puncture is not medically necessary for isolated symptoms of headache or sleep apnea that do not meet the criteria for sinusitis.; Para-nasal sinus mucocele coverage excludes benign, asymptomatic mucus retention cysts (not covered as a mucocele indication). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0937 — Sinus Surgeries

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0937 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.