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12465 Results

Balloon Ostial Dilation

Service Code
31297 (CPT) Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Service Code
31298 (CPT) Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Unlisted procedure, accessory sinuses

Service Code
31299 (CPT) Unlisted procedure, accessory sinuses
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Laryngotomy (thyrotomy, laryngofissure), with removal of tumor or laryngocele, cordectomy

Service Code
31300 (CPT) Laryngotomy (thyrotomy, laryngofissure), with removal of tumor or laryngocele, cordectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngectomy; total, without radical neck dissection

Service Code
31360 (CPT) Laryngectomy; total, without radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngectomy; total, with radical neck dissection

Service Code
31365 (CPT) Laryngectomy; total, with radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngectomy; subtotal supraglottic, without radical neck dissection

Service Code
31367 (CPT) Laryngectomy; subtotal supraglottic, without radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngectomy; subtotal supraglottic, with radical neck dissection

Service Code
31368 (CPT) Laryngectomy; subtotal supraglottic, with radical neck dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Partial laryngectomy (hemilaryngectomy); horizontal

Service Code
31370 (CPT) Partial laryngectomy (hemilaryngectomy); horizontal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Partial laryngectomy (hemilaryngectomy); laterovertical

Service Code
31375 (CPT) Partial laryngectomy (hemilaryngectomy); laterovertical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Partial laryngectomy (hemilaryngectomy); anterovertical

Service Code
31380 (CPT) Partial laryngectomy (hemilaryngectomy); anterovertical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Partial laryngectomy (hemilaryngectomy); antero-latero-vertical

Service Code
31382 (CPT) Partial laryngectomy (hemilaryngectomy); antero-latero-vertical
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pharyngolaryngectomy, with radical neck dissection; without reconstruction

Service Code
31390 (CPT) Pharyngolaryngectomy, with radical neck dissection; without reconstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pharyngolaryngectomy, with radical neck dissection; with reconstruction

Service Code
31395 (CPT) Pharyngolaryngectomy, with radical neck dissection; with reconstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Arytenoidectomy or arytenoidopexy, external approach

Service Code
31400 (CPT) Arytenoidectomy or arytenoidopexy, external approach
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Epiglottidectomy

Service Code
31420 (CPT) Epiglottidectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Intubation, endotracheal, emergency procedure

Service Code
31500 (CPT) Intubation, endotracheal, emergency procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tracheotomy tube change prior to establishment of fistula tract

Service Code
31502 (CPT) Tracheotomy tube change prior to establishment of fistula tract
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngoscopy, indirect; diagnostic (separate procedure)

Service Code
31505 (CPT) Laryngoscopy, indirect; diagnostic (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Laryngoscopy, indirect; with biopsy

Service Code
31510 (CPT) Laryngoscopy, indirect; with biopsy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required