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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

September 2017

Updates to Sinus Surgeries Medical Review Criteria


Effective Dec. 1, 2017, Harvard Pilgrim is updating our medical review criteria for sinus surgeries, and renaming the policy Endoscopic Sinus Surgeries Medical Review Criteria. 

In addition to the name change, Harvard Pilgrim is clarifying and adding detail to coverage exclusions and the criteria that must be met in order for endoscopic sinus surgeries to be covered, creating criteria specific to balloon sinuplasty, and adding the following CPT codes as eligible for coverage with prior authorization:  

  • 31231 – Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
  • 31233 – Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)
  • 31235 – Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium)
  • 31237 – Nasal/sinus endoscopy, surgical with biopsy, polypectomy or debridement (separate procedure)
  • 31238 – Nasal/sinus endoscopy, surgical with control of nasal hemorrhage
  • 31239 – Nasal/sinus endoscopy, surgical with dacryocystorhinostomy
  • 31240 – Nasal/sinus endoscopy, surgical with concha bullosa resection
  • 31287 – Nasal/sinus endoscopy, surgical, with sphenoidotomy
  • 31290 – Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak ethmoid region
  • 31291 – Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak sphenoid region
  • 31292 – Nasal/sinus endoscopy, surgical with medial or inferior orbital wall decompression
  • 31297 – Nasal/sinus endoscopy, surgical with dilation of sphenoid sinus ostium (e.g., balloon dilation)
  • 30130 – Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps
  • 30140 – Pterygomaxillary fossa surgery, any approach

For more information, including complete coverage criteria and exclusions, refer to the updated Endoscopic Sinus Surgeries Medical Review Criteria.

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