Use of a catheter-based inflatable device (balloon ostial dilation) for the treatment of chronic rhinosinusitis in the sinus being considered for dilation may be medically necessary when the following criteria are present:
Patient is 18 years of age or older (see Policy Guidelines for younger ages).
AND
Chronic rhinosinusitis without nasal polyps that negatively impacts quality of life, characterized by at least two of the following, at least one of which is (a) or (b), present for at least 12 continuous weeks:
Mucopurulent nasal drainage (anterior, posterior, or both);
Nasal obstruction (congestion);
Facial pain-pressure-fullness;
Decreased sense of smell.
AND
Optimal medical therapy has been attempted and failed, as indicated by all of the following:
Allergy evaluation, education, and optimal treatment when indicated;
Two 10-day courses of antibiotics, or one prolonged course of at least 21 days duration;
Decongestants when indicated;
Topical and/or systemic corticosteroids for at least 8 weeks;
Saline nasal irrigation for at least 8 consecutive weeks;
Treatment of rhinitis medicamentosa (rebound nasal congestion due to extended use of topical decongestants), when present;
Education on environmental irritants including tobacco smoke.
AND
Clinical and radiographic documentation of persistent inflammation following optimal medical therapy (see Policy Guidelines).
The use of balloon ostial dilation for the treatment of chronic rhinosinusitis is considered investigational when the above criteria are not met.
The use of balloon ostial dilation for the treatment of recurrent acute rhinosinusitis is considered investigational.
