December 1, 2012
Last Revised Date:
January 22, 2018
Provide guidelines for the reimbursement of balloon sinuplasty when used as an add on to functional endoscopic sinus surgery (FESS).
All products are included except for products where Horizon is secondary to Medicare (i.e. Medigap).
All Insured and ASO accounts are included.
This policy is to document Horizon's position of not reimbursing separately for the balloon sinuplasty procedure when performed as an adjunct to FESS procedures.
Chronic sinusitis is a medical condition that may be treated surgically with endoscopic surgery, usually coded with CPT® codes 31256, 31267, 31276, 31287, and 31288. The CPT codes 31295, 31296 and 31297 may be used to represent the use of balloon sinuplasty during the surgical procedure.
Balloon sinuplasty as a standalone procedure for the treatment of chronic sinusitis is investigational according to Horizon Uniform Medical Policy #077 Surgery. This position is consistent with the BCBSA Medical Policy Reference Manual, which provides additional guidance which states:
“Beginning in 2011, there are specific category I CPT codes for these procedures (31295-31297). These codes may be used to describe balloon sinuplasty when no other surgical intervention has been performed on the same sinus site.
- If balloon sinuplasty is performed in conjunction with cutting tools such as curettes and forceps, the procedure might be coded using the CPT codes for nasal/sinus endoscopy with maxillary antrostomy (31256), nasal/sinus endoscopy with frontal sinus exploration, including removal of tissue from frontal sinus, when performed (31276), or nasal/sinus endoscopy with sphenoidectomy (31287). Plans should be aware of this possibility. In this instance, the balloon dilation would be considered inclusive/incidental to the procedure.”
The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Deny the balloon sinuplasty procedure codes (31295, 31296, and 31297) as incidental when performed in conjunction FESS (31256, 31267, 31276, 31287, and 31288).
In instances where the provider is participating, there shall be no member liability.
In instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
Group or Individual benefit.
Provider Participation Agreement.
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
Mandated or legislative required criteria will always supersede.
01/22/2018: Policy section revised to reflect CMS’s revised definition for CPT 31276
CPT® is a registered trademark of the American Medical Association.