Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

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

February 2018

Endoscopic Sinus Surgeries Medical Review Criteria Updates

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.

Email this article to a colleague   

Network Matters Archives

Download printer-friendly version


Changes to Negative Balance and Refund Processes

Maximum Dosages for Medical Drugs

Reminder: Prior Authorization for Genetic Testing

Saheli Boston Can Help Meet the Needs of South Asian Patients


Prior Authorization for Diabetes Management Devices

Coverage of Exondys 51 with Prior Authorization

PCP Cardiac Medication Adherence Report

Member Blood Pressure Quiz

Endoscopic Sinus Surgeries Medical Review Criteria Updates

Lyme/Tick-Borne Diseases: Use of Parenteral Antibiotics Criteria

P&T Committee Meeting Update

Specialty Pharmacy Update

Members’ Rights and Responsibilities

HEDIS Spotlight: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)


Reminder: Use the Correct Form for Provider Changes for Quicker Service


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator