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31297

PAYER POLICY CHANGES

31297 Insurance Policy Changes

CPT 31297, in plain terms, covers Endoscopic dilation of the sphenoid sinus opening, typically with a balloon catheter, to improve drainage. CPT 31297 is referenced in 22 tracked payer policy changes from Ambetter, Premera Blue Cross, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 31297 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 31297 on AAPC

Ambetter · Effective Jan 1, 2027High impact
August Provider Newsletter
Ambetter of North Carolina will stop covering a list of HCPCS H codes starting January 1, 2027, and will cover H0006 from that date. Earlier changes are already effective: CPT 80320-80377 drug testing codes were no longer reimbursable from October 1, 2026, and the prior authorization changes effective October 1, 2026 took effect. The newsletter also covers surrogacy diagnosis codes Z33.3 and Z31.7, behavioral health type of bill guidance, and clinical policy updates effective 11/1/2026.
Ambetter · Effective Oct 1, 2026High impact
Ambetter of Tennessee Q3 2026 Newsletter
Already effective October 1, 2026, prior authorization is removed for genetic testing codes 86812, 86813, and 86817, home visit codes S9211, S9213, and S9214, and medical transportation mileage code 38208, while sinus surgery code 31297 now requires prior authorization. CPT codes 80320 through 80377 for definitive drug testing are no longer reimbursable as of October 1, 2026. Effective December 5, 2026, Evolent will guide ordering providers to select a preferred site of care for shoulder, hip, knee, and spine surgeries, and effective January 1, 2027, Evolent will require prior authorization for listed cardiology and vascular procedure codes.
Ambetter · Effective Oct 1, 2026High impact
Q3 2026 Provider Newsletter
Ambetter of Alabama updated its prior authorization requirements effective Oct. 1, 2026. The updated table lists genetic testing codes 81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813 and 86817 as No PA Required, sinus procedure codes 31296 and 31297 as PA Required, and transplant code 38208 as No PA Required. Starting Dec. 5, 2026, Evolent will guide ordering providers to select a preferred site of care when they submit authorization requests for shoulder, hip, knee and spine surgeries.
Premera Blue Cross · Effective Feb 6, 2026High impact
Medical Policy and Coding Updates - November 2025
Premera HMO plans in Washington have changes from the November 2025 medical policy and coding update. Fifty Routine Test Management policies for laboratory services are effective February 6, 2026, and the notice says they are managed through claims edits for rule-based criteria and are not prior authorization. Other dated items include new medical necessity and prior authorization review for several coded services and Federal Employee Program prior authorization for certain drugs, all listed with an effective date of February 6, 2026.
Premera Blue Cross · Effective Jan 2, 2026High impact
Medical Policy and Coding Updates - October 2025
Premera HMO plans in Washington have changes from the October 2025 medical policy and coding update. Dated items include the Abdominal Wall Hernia policy and its codes effective January 2, 2026, advanced imaging site-of-care review through Carelon and a Washington mandate for medical clearance of minors' hearing aid coverage effective January 1, 2026, and Federal Employee Program prior authorization for hip, knee and spine surgery effective January 1, 2026. Several biologic and drug policies also moved products between preferred and non-preferred status.
Premera Blue Cross · Effective Jan 1, 2026High impact
Medical Policy and Coding Updates - September 2025
Premera HMO plans in Washington have changes from the September 2025 medical policy and coding update. The lead item is advanced imaging site-of-care review through Carelon Medical Benefits Management, Inc., effective January 1, 2026 for dates of service on and after that date. Many coded services also now require review for medical necessity and prior authorization, including negative pressure wound therapy, oncology drugs, percutaneous coronary intervention and selected ASC surgical procedures.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026High impact
Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis
The 2025-07-01 revision changed balloon ostial dilation for chronic rhinosinusitis from investigational to medically necessary when the listed criteria are met. Those criteria cover adults 18 and older with chronic rhinosinusitis without nasal polyps, optimal medical therapy that has been attempted and failed, and documented persistent inflammation. Balloon ostial dilation for recurrent acute rhinosinusitis is considered investigational.
Premera Blue Cross · Identified Jun 16, 2026High impact
Medical Policy and Coding Updates - August 2025
Effective January 1, 2026, site of service is reviewed for advanced imaging services under Carelon Medical Benefits Management's Site of Care for Advanced Imaging criteria, and hospital outpatient site of care is considered medically necessary when ancillary services are required and not available at freestanding centers in the same geographic area. Effective November 7, 2025, bariatric surgery reoperation for inadequate weight loss is considered medically necessary if the original procedure fails, such as unsuccessful band adjustments, resulting in less than 50% excess weight loss or less than 20% total weight loss. Effective November 7, 2025, select surgical procedures previously reviewed for site of service in the inpatient setting are reviewed for site of service in the ambulatory surgical center setting under policy 11.01.525.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Meridian is removing prior authorization requirements for genetic testing, home visit services, and transplant services, while adding prior authorization requirements for specific sinus surgery procedures (31296, 31297, 31298), effective October 1, 2026. These changes apply across Ambetter's markets and lines of business to simplify the prior authorization process.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates
Ambetter from Magnolia Health is updating prior authorization requirements effective October 1, 2026. Genetic testing (CPT 81378-81383, 86812-86813, 86817), home services (S9211, S9213, S9214), and transplant services (CPT 38208) no longer require prior authorization, while sinus surgery (CPT 31297) now requires prior authorization. These changes standardize PA requirements across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Buckeye Health Plan is removing prior authorization requirements for genetic testing, obstetrical home services, and transplant services for participating providers effective October 1, 2026. Simultaneously, prior authorization is now required for sinus surgery (CPT 31297). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter of Alabama is updating prior authorization (PA) requirements effective October 1, 2026, removing PA requirements for genetic testing (CPT 86812, 86813, 86817) and transplant services (CPT 38208), while adding PA requirements for sinus surgery procedures (CPT 31296, 31297). These changes aim to reduce administrative burden and standardize PA processes across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter Health is updating prior authorization requirements effective October 1, 2026. The changes remove PA requirements for genetic testing (86812, 86813, 86817), home services (S9211, S9213, S9214), and transplant services (38208), while adding PA requirements for sinus surgery procedures (31276, 31296, 31297, 31298). These changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter Health of Delaware is updating prior authorization (PA) requirements effective October 1, 2026. Genetic testing (CPT 86812, 86813, 86817) and home visit services (HCPCS S9211, S9213, S9214) are moving to NO PA REQUIRED, while sinus surgery procedures (CPT 31276, 31296, 31297, 31298) now require PA. Changes aim to reduce administrative burden and create uniform PA requirements across markets.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Absolute Total Care is removing prior authorization requirements for genetic testing, home services, and transplant services effective October 1, 2026, while adding prior authorization requirements for specific sinus surgery procedures. These changes aim to reduce administrative burden and streamline the PA process across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates: Effective October 1, 2026
Ambetter from Arizona Complete Health is removing prior authorization requirements for genetic testing (CPT 86812, 86813, 86817), home services (HCPCS S9211, S9213, S9214), and transplant services (CPT 38208), while adding prior authorization requirements for sinus surgery procedures (CPT 31276, 31296, 31297, 31298). These changes take effect October 1, 2026, and aim to reduce administrative burden and simplify the PA process across markets and lines of business.
Ambetter · Effective Oct 1, 2026Medium impact
Important Prior Authorization Updates (Effective October 1, 2026)
Ambetter Health is simplifying prior authorization requirements effective October 1, 2026, by removing PA requirements for genetic testing, home services, and transplant services, while adding PA requirements for specific sinus surgery procedures (31296, 31297). This change aims to reduce administrative burden and create uniform PA requirements across all markets and lines of business.
Excellus BlueCross BlueShield · Effective Aug 20, 2026Medium impact
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) 7.01.85
Balloon sinus ostial dilation, also called balloon sinuplasty, or any other catheter-based inflatable device is considered medically appropriate as a stand-alone procedure for chronic rhinosinusitis when all criteria are met. Those criteria are documentation of two or more cardinal symptoms for more than three months, failed medical therapy with steroid nasal spray and saline irrigation for at least 8 weeks each, and objective evidence of chronic rhinosinusitis after optimal medical therapy. Balloon dilation for recurrent acute rhinosinusitis is considered investigational, and self-expanding absorptive sinus ostial dilation is considered investigational for all indications.
Humana · Effective Apr 1, 2026Medium impact
Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)
This is a historical Medicare Advantage medical coverage policy for sinonasal and Eustachian tube surgical procedures that became effective on 04/01/2026. The policy was reviewed on 03/10/2026 and newly discovered on 10/06/2026. It establishes medical necessity criteria for BDET, balloon sinus ostial dilation, FESS, PNN ablation, and steroid-eluting sinus implants. The billing team should verify current applicability and confirm whether this policy remains in effect, as discovery does not establish freshness.
Humana · Effective Apr 1, 2026Medium impact
Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)
Humana Medicare Advantage has updated coverage criteria for sinonasal and eustachian tube surgical procedures, establishing specific medical necessity requirements for balloon dilation procedures, functional endoscopic sinus surgery, and related interventions. The policy defines detailed documentation requirements including physical exams, diagnostic workup, and failed medical therapy before surgical intervention will be covered.
Aetna · Identified Aug 16, 2026Medium impact
Sinus Surgeries (CPB 0937, reviewed 2026-04-10)
Aetna's Clinical Policy Bulletin 0937 treats endoscopic sinus surgery as medically necessary for specific indications, including allergic fungal rhino-sinusitis with CT evidence, antro-choanal polyp, chronic rhino-sinusitis longer than 12 continuous weeks with or without nasal polyps that has failed maximal medical treatment and shows objective CT evidence, recurrent acute rhino-sinusitis meeting listed criteria, sinusitis complications, and mucocele, and as experimental, investigational, or unproven for all other indications. Revision surgery requires at least 12 weeks since the previous surgery, chronic rhino-sinusitis for at least 12 continuous weeks, failure of at least one 5 to 7 day course of antibiotics since the previous surgery, and persistent objective CT evidence of sinus disease. Balloon sinus ostial dilation is medically necessary for uncomplicated sinusitis without nasal polyposis when the Appendix criteria are met and is experimental for listed cases such as nasal polyposis grade 2 or greater, repeat balloon procedures, and Samter's triad, while sphenopalatine artery ligation with posterior nasal nerve ablation is experimental for vasomotor rhinitis.
Premera Blue Cross · Identified Jun 18, 2026Medium impact
Medical Policy and Coding Updates - June 2018
Effective June 1, 2018, drugs for rare diseases (J0180, J0221, J1322, J1743, J1786, J3385) and breast reconstruction with DIEP or stacked flaps (S2067, S2068) now require medical necessity review and prior authorization, and coronary angiography codes 93454 through 93461 now require prior authorization. Effective June 1, 2018, intraoperative neurophysiologic monitoring codes 95940, 95941 and G0453 now require medical necessity review, while codes 95925 through 95939 and 95930 are no longer reviewed for medical necessity or investigational status. For several surgical and device services (including knee arthroscopy 29871 through 29889, lumbar decompression 63005 through 63272, sinus surgery 31254 through 31297, rhinoplasty 30400 through 30450, spinal cord stimulation 63650 through L8688, and snoring surgery 42145), medical necessity criteria now include site of service, effective June 1, 2018. Effective July 5, 2018, codes 43201, 43236 and 43257 are investigational for all uses, and revised pharmacy policies added Aimovig, Kymriah, Tremfya, Xeljanz for plaque psoriasis, and Rubraca in combination with Opdivo and Yervoy, while removing Xeljanz for ulcerative colitis.

Watch 31297

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REFERENCE DATA

Payers with rules16

Payers requiring prior auth16

Aetna · Effective November 1, 2026
Prior authorization required
Participating provider precertification list for Aetna
Anthem BCBS · Effective November 1, 2026
Prior authorization required
Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial)
Blue Shield of California · Effective November 1, 2026
Prior authorization required
Prior Authorization List for Blue Shield Medicare

FREQUENTLY ASKED QUESTIONS

Does Aetna require prior authorization for 31297?

Aetna lists 31297 on Participating provider precertification list for Aetna for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Ambetter require prior authorization for 31297?

Ambetter lists 31297 on Ambetter from Superior HealthPlan 87226 CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does AmeriHealth Caritas require prior authorization for 31297?

AmeriHealth Caritas lists 31297 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 31297?

Anthem BCBS lists 31297 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does BCBS Illinois require prior authorization for 31297?

BCBS Illinois lists 31297 on 2026 Commercial Outpatient Medical Surgical Prior Authorization Codes for commercial plans, with conditions (list dated January 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 31297?

There are 22 tracked policy changes affecting CPT 31297, including updates from Ambetter, Premera Blue Cross, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 31297?

Payers that have issued tracked updates for CPT 31297 include: Ambetter, Premera Blue Cross, Blue Cross & Blue Shield of Mississippi, Excellus BlueCross BlueShield, Humana, Aetna.

How do I get notified when CPT 31297 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 31297. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 31297?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for 31297

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 31297 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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August Provider Newsletter

Ambetter of Tennessee Q3 2026 Newsletter

Q3 2026 Provider Newsletter

Medical Policy and Coding Updates - November 2025

Medical Policy and Coding Updates - October 2025

Medical Policy and Coding Updates - September 2025

Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

Medical Policy and Coding Updates - August 2025

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates: Effective October 1, 2026

Important Prior Authorization Updates (Effective October 1, 2026)

Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) 7.01.85

Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)

Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)

Sinus Surgeries (CPB 0937, reviewed 2026-04-10)

Medical Policy and Coding Updates - June 2018

Prior authorization required

Prior authorization required

Prior authorization required

Does Aetna require prior authorization for 31297?

Does Ambetter require prior authorization for 31297?

Does AmeriHealth Caritas require prior authorization for 31297?

Does Anthem BCBS require prior authorization for 31297?

Does BCBS Illinois require prior authorization for 31297?

What insurance policy changes affect CPT 31297?

Which payers have updated policy for CPT 31297?

How do I get notified when CPT 31297 policy changes?

Why do payers change policies for CPT 31297?