Medicare AdvantagePrior AuthMedium impact
Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)
Humana·ENT (Ear, Nose & Throat)·Medicare Advantage
We identified it
Jul 28, 2026
Summary
This Medicare Advantage policy defines coverage criteria for minimally invasive sinonasal and Eustachian tube surgical procedures. Coverage requires that patients have chronic or recurrent disease and have failed appropriate medical management prior to surgery. Billing teams must ensure prior authorization processes verify these prerequisites before claims submission.
Action Required
Immediately: Billing team must implement prior authorization verification for all sinonasal and Eustachian tube endoscopic/catheter-based procedures submitted to this Medicare Advantage plan. Before claim submission, verify in the authorization system that: (1) patient has documented chronic or recurrent sinonasal/ET disease, and (2) medical records confirm failure of appropriate conservative medical management. Add a checklist item to the pre-authorization workflow and train billing staff to request supporting documentation from providers if not present. Claims submitted without verification of these prerequisites will likely be denied. Update encounter templates to prompt providers to document prior medical management attempts.