Transcription of Balloon Sinus Ostial Dilation - UHCprovider.com
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Balloon Sinus Ostial Dilation - UHCprovider.com
UnitedHealthcare Commercial Medical Policy Balloon Sinus Ostial Dilation Policy Number: 2021T0571K. Effective Date: August 1, 2021 Instructions for Use Table of Contents Page Related Commercial Policy Coverage 1 Functional Endoscopic Sinus Surgery (FESS). Documentation 2. 3 Community Plan Policy Applicable Codes .. 3 Balloon Sinus Ostial Dilation Description of 4 Medicare Advantage Coverage Summary Clinical Evidence .. 4. Nasal and Sinus Procedures Food and Drug References ..12. Policy History/Revision Instructions for Use ..14. Coverage Rationale Balloon Sinus Ostial Dilation is proven and medically necessary for either of the following conditions: Chronic Rhinosinusitis which has all of the following: o Lasted longer than 12 weeks o Persistence of symptoms despite administration of full courses of all of the following treatments: Antibiotic therapy, if bacterial infection is suspected, and Intranasal corticosteroids, and Nasal lavage o Confirmation of Chronic Rhinosinusitis on a computed tomography (CT) scan for each Sinus to be dilated meeting all of the following criteria: CT images are obtained after completion of medical management, and Documentation of which Sinus has the disease and the extent of disease including the percent of opacificatio
o Confirmation of Chronic Rhinosinusitsi on a computed tomography (CT) scan for each sinus to be dilated meeting all of the following criteria: CT images are obtained after compel tio n of medical management , and Documentation of which sinus has the disease and the extent of disease including the percent of opacfiicatoi n or
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