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Prior Authorization for Functional Endoscopic Sinus Surgery

Apr 01, 2016

Beginning May 2, 2016, some functional endoscopic sinus surgery procedures will be added to UnitedHealthcare's prior authorization list for many commercial plans and Community Plans (Medicaid), excluding Medicare Dual Special Needs Plans (DNSPs) and Medicare Medicaid Plans (MMPs). 

This is part of UHC's ongoing responsibility to regularly evaluate their medical policies, clinical programs and health benefits against the latest scientific evidence and specialty society guidance, as their member benefit plans require care to be medically appropriate. Using evidence-based medicine to guide coverage decisions supports quality patient care and reflects their shared commitment to the Triple Aim: better care, better health and lower costs. 

The prior authorization requirement for these procedures applies to the following UnitedHealthcare plans, including Health Care Exchange plans, beginning with dates of service on and after May 2, 2016, in most states*:

*For UnitedHealthcare commercial members in Illinois and Iowa, and for UnitedHealthcare Community Plan Medicaid members in Iowa and New Mexico, these guidelines apply to dates of service on or after July 1, 2016. 

Medical necessity reviews will be required for all UnitedHealthcare Community Plans and commercial members for these procedures in all states. 

The following answers to frequently asked questions provide more details. 

Which functional endoscopic sinus surgery procedures will require prior authorization?
A. The prior authorization requirement applies to the following procedures:

CPT code

Description

31237

Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement

31238

Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage

31239

Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy

31240

Nasal/sinus endoscopy, surgical; with concha bullosa resection

31254

Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)

31255

Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)

31256

Nasal/sinus endoscopy, surgical, with maxillary antrostomy;

31267

Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus

31276

Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

31287

Nasal/sinus endoscopy, surgical, with sphenoidotomy

31288

Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

When does the prior authorization requirement become effective?
A. The prior authorization requirement becomes effective in most states for dates of service on or after May 2, 2016. Please note the following exceptions:

You can view the FAQ document here.

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