PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical; with concha bullosa resection
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior)
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior)
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical, with maxillary antrostomy;
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Nasal/sinus endoscopy, surgical, with sphenoidotomy;
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with orbital decompression; medial or inferior wall
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with orbital decompression; medial and inferior wall
How to Submit
N/A - No authorization is required
Nasal/sinus endoscopy, surgical, with optic nerve decompression
How to Submit
N/A - No authorization is required
Balloon Ostial Dilation
Balloon Ostial Dilation (BOD) also known as balloon dilation sinuplasty, balloon catheter sinusotomy, sinus ostial dilation or balloon sinuplasty, is a procedure that involves placing a balloon in the sinus ostium and inflating the balloon to stretch the opening. BOD can be performed as a stand-alone procedure for chronic rhinosinusitis, or as an adjunctive procedure to the traditional endoscopic sinus surgery, Functional Endoscopic Sinus Surgery (FESS). Several procedure approaches have been proposed for balloon sinus ostial dilation. The first type of approach is done through the nostrils by inserting a small balloon through a tube placed in the nasal cavity where the blocked sinus is located using fluoroscopic guidance. The second type of approach is the transantral approach, which is done by creating a small entry point under the lip. In most instances, the procedure is performed under general anesthesia and in some cases local anesthesia. Potential advantages of sinus balloon catheterization consist of minimal mucosal damage, minimal intraoperative bleeding, minimal discomfort, and equally effective when compared with the more invasive procedure of FESS. This policy does not address FESS.
Authorization Guidelines
The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in this policy.
In addition to the requirements listed in the Clinical Coverage Policy, the Otolaryngologist shall submit all of the following to the DHHS Utilization Review Contractor:
- a. Signed letter of medical necessity by the attending physician requesting
BOD, and a summary of the beneficiary’s clinical history and evaluation.
- b. Documentation of what sinus is involved;
- c. Documentation of attempted and failed medical therapy for persistent chronic or recurrent acute rhinosinusitis;
- d. Documentation of one or more of the following CT scan findings:
- 1. mucosal thickening greater than two millimeters;
- 2. complete opacification;
- 3. bone remodeling and thickening; or
- 4. obstruction of the ostiomeatal complex.
Note: CT scans can be nonspecific for diagnosing RARS, therefore, clinical findings are required to support surgical intervention.
Limits
With prior approval, Medicaid will pay each code (31295, 31296, 31297, 31298) one time, per sinus, per beneficiary lifetime.
Exclusions
Medicaid shall not cover BOD for any of the following conditions:
- a. Nasal polyps or tumors.
- b. Samter’s Triad (aspirin sensitivity);
- c. Severe sinusitis secondary to autoimmune or connective tissue disorders such as sarcoidosis or Wegener’s granulomatosis;
- d. Severe sinusitis secondary to ciliary dysfunction such as cystic fibrosis;
- e. Contraindication to, or inability to tolerate local or topical anesthetic;
- f. History of failed balloon procedure in the sinus to be treated;
- g. Sinusitis with extensive fungal disease; or
- h. Significant neo-osteogenesis confirmed by CT.
Place of Service
Inpatient hospital, outpatient hospital, ambulatory surgical clinic, and office.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Balloon Ostial Dilation
Balloon Ostial Dilation (BOD) also known as balloon dilation sinuplasty, balloon catheter sinusotomy, sinus ostial dilation or balloon sinuplasty, is a procedure that involves placing a balloon in the sinus ostium and inflating the balloon to stretch the opening. BOD can be performed as a stand-alone procedure for chronic rhinosinusitis, or as an adjunctive procedure to the traditional endoscopic sinus surgery, Functional Endoscopic Sinus Surgery (FESS). Several procedure approaches have been proposed for balloon sinus ostial dilation. The first type of approach is done through the nostrils by inserting a small balloon through a tube placed in the nasal cavity where the blocked sinus is located using fluoroscopic guidance. The second type of approach is the transantral approach, which is done by creating a small entry point under the lip. In most instances, the procedure is performed under general anesthesia and in some cases local anesthesia. Potential advantages of sinus balloon catheterization consist of minimal mucosal damage, minimal intraoperative bleeding, minimal discomfort, and equally effective when compared with the more invasive procedure of FESS. This policy does not address FESS.
Authorization Guidelines
The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in this policy.
In addition to the requirements listed in the Clinical Coverage Policy, the Otolaryngologist shall submit all of the following to the DHHS Utilization Review Contractor:
- a. Signed letter of medical necessity by the attending physician requesting
BOD, and a summary of the beneficiary’s clinical history and evaluation.
- b. Documentation of what sinus is involved;
- c. Documentation of attempted and failed medical therapy for persistent chronic or recurrent acute rhinosinusitis;
- d. Documentation of one or more of the following CT scan findings:
- 1. mucosal thickening greater than two millimeters;
- 2. complete opacification;
- 3. bone remodeling and thickening; or
- 4. obstruction of the ostiomeatal complex.
Note: CT scans can be nonspecific for diagnosing RARS, therefore, clinical findings are required to support surgical intervention.
Limits
With prior approval, Medicaid will pay each code (31295, 31296, 31297, 31298) one time, per sinus, per beneficiary lifetime.
Exclusions
Medicaid shall not cover BOD for any of the following conditions:
- a. Nasal polyps or tumors.
- b. Samter’s Triad (aspirin sensitivity);
- c. Severe sinusitis secondary to autoimmune or connective tissue disorders such as sarcoidosis or Wegener’s granulomatosis;
- d. Severe sinusitis secondary to ciliary dysfunction such as cystic fibrosis;
- e. Contraindication to, or inability to tolerate local or topical anesthetic;
- f. History of failed balloon procedure in the sinus to be treated;
- g. Sinusitis with extensive fungal disease; or
- h. Significant neo-osteogenesis confirmed by CT.
Place of Service
Inpatient hospital, outpatient hospital, ambulatory surgical clinic, and office.
How to Submit
Please submit your request to Trillium Health Resources
Resources
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