Effective November 1, 2022, Blue Cross Complete (BCC) will be using Change Healthcare’s InterQual criteria to make utilization management determinations about balloon ostial dilation (balloon sinuplasty). Outpatient, office-based, or hospital/ambulatory balloon sinus ostial dilation and functional endoscopic sinus surgery performed as an alternative to traditional endoscopic sinus surgery for the treatment of dilating obstructed sinuses (maxillary, frontal, or sphenoid) related to refractory cases of chronic, uncomplicated rhinosinusitis confirmed by computed tomography scan is covered when medically necessary and the following criteria are met:

Uncomplicated chronic rhinosinusitis limited to the paranasal sinuses without the involvement of adjacent neurological, soft tissue, or bony structures that has persisted for at least 12 weeks with at least two of the following sinonasal symptoms:

• Facial pain/pressure
• Hyposmia/anosmia
• Nasal obstruction
• Mucopurulent nasal discharge, and
• Sinonasal symptoms that are persistent after maximal medical therapy has been attempted, as defined by all of the following, either sequentially or overlapping:
  • Saline nasal irrigation for at least six weeks
  • Nasal corticosteroids for at least six weeks
  • Approved biologics, if applicable, for at least six weeks
  • A complete course of antibiotic therapy when an acute bacterial infection is suspected
  • Treatment of concomitant allergic rhinitis, if present; and
• Objective evidence of sinonasal inflammation as determined by one of the following:
  • Nasal endoscopy, or
  • Computed tomography

Click here to read the full announcement from Blue Cross Complete.