Harvard Pilgrim is making some updates to our commercial prior authorization policy for endoscopic sinus surgeries. Effective for dates of service beginning Feb. 22, 2018, coverage for the following CPT codes will require prior authorization:
- 31040 – Pterygomaxillary fossa surgery, any approach
- 31253 – Nasal/sinus endoscopy, surgical with ethimoidectomy total including frontal sinus exploration, with removal of tissue from sinus, when performed
- 31257 – Nasal/sinus endoscopy, surgical with ethimoidectomy total including sphenoidotomy
- 31259 – Nasal/sinus endoscopy, surgical with ethimoidectomy total including sphenoidotomy, with removal of tissue from the sphenoid sinus
- 31298 – Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)
In addition, the following codes were removed from the policy as of Dec. 22, 2017 and no longer require 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)
- 30140 – Submucous resection inferior turbinate, partial or complete, any method
For complete information, please refer to Harvard Pilgrim’s updated Endoscopic Sinus Surgeries Medical Review Criteria.