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Medical Policy: 07.01.31
Original Effective Date: May 2006
Reviewed: January 2012
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Functional endoscopic dilatation of the sinuses, also referred to as Balloon SinuplastyTM describes a procedure intended to clear sinus cavities using a balloon rather than invasive surgery. During this endoscopic procedure, a catheter-based device is advanced into the sinus under fluoroscopic guidance. Once positioned the balloon is gradually inflated to open the sinus thereby allowing drainage.
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Prior Approval:
Not applicable
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Policy:
Functional endoscopic dilatation of the sinuses or Balloon Sinuplasty™ is considered investigational as a stand-alone procedure.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- S2344 Nasal/sinus endoscopy, surgical; with enlargement of sinus ostium opening using inflatable device (i.e., balloon sinuplasty)
- 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)
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Selected References:
- Brown CL, Bolger WE. Safety and feasibility of balloon catheter dilation of paranasal sinus ostia: a preliminary investigation. Ann Otol Rhinol Laryngol 2006: 115(4):293-9.
- ECRI Technology Target Database. Endoscopic Balloon Dilatation of Paranasal Sinuses for Sinusitis. January 2007.
- Weiss RL, Church CA, Kuhn FA et al. Long-term outcomes analysis of balloon catheter sinusotomy: two-year follow-up. Otolaryngol Head neck Surg 2008 Sep; 139(3 Suppl 3): S38-46.
- Kuhn FA, Church, Goldberg AN et al. Balloon catheter sinusotomy: one-year follow-up - Outcomes and role in functional endoscopic surgery. Otolaryngol Head Neck Surg 2008 Sep; 139(3 Suppl 3); S27-37.
- Vaughan WC, Review of balloon sinuplasty. Curr Opin Otolaryngol Head Neck Surg. 2008 Feb; 16(1): 2-9.
- TARGET [database online]. Plymouth Meeting (PA): ECRI Institute; 2008 Dec 19; Balloon catheter dilation for chronic sinusitis. Available: http://www.ecri.org.
- Levine HL, Sertich AP 2nd, Hoisington DR et al. Multicenter registry of balloon catheter sinusotomy outcomes for 1,036 patients. Ann Otol Rhinol Laryngol. 2008 Apr;117(4):263-70.
- Wittkopf ML, Becker SS, Duncavage JA et al. Balloon sinuplasty for the surgical management of immunocompromised and critically ill patients with acute rhinosinusitis. Otolaryngol Head Neck Surg. 2009 Apr; 140(4):596-8.
- Batra PS, Ryan MW, Sindwani R et al. Balloon catheter technology in rhinology: Reviewing the evidence. Laryngoscope. 2011 Jan; 121(1):226-32. doi: 10.1002/lary.21114. Epub 2010 Sep 7.
- TARGET [database online]. Plymouth Meeting (PA): ECRI Institute; 2010 May 3; Balloon catheter dilation for chronic sinusitis. Available: http://www.ecri.org.
- Plaza G, Eisenberg G, Montojo J, Onrubia T, Urbasos M, O’Connor C. Balloon dilation of the frontal recess: A randomized clinical trial. Ann Otol Rhinol Laryngol. 2011 Aug;120(8):511-8.
- Ahmed J, Pal S, Hopkins C, Jayaraj S. Functional endoscopic balloon dilation of sinus ostia for chronic rhinosinusitis. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD008515.
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Policy History:
Date Reason Action
January 2011 Annual review Policy renewed
January 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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