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Sinus Surgeries (CPB 0937, reviewed 2026-04-10)
Aetna·ENT (Ear, Nose & Throat)·Medical Policy
Effective date
Apr 10, 2026
We identified it
Aug 16, 2026
Summary
Aetna updated its Clinical Policy Bulletin 0937 for sinus surgeries, establishing comprehensive medical necessity criteria for endoscopic sinus surgery (ESS), revision ESS, balloon sinuplasty, image-guided ESS, and post-operative debridement. The policy specifies strict documentation requirements including CT imaging within 12 months, failed conservative treatment thresholds (5-7 days antibiotics, 6 weeks intranasal corticosteroids), and objective evidence of disease. Billing teams must ensure prior authorization submissions include complete medical documentation and imaging reports meeting these criteria.
Action Required
Before April 10, 2026: Billing team must implement the following: (1) Update prior authorization submission requirements to mandate CT imaging reports dated within 12 months showing objective findings (obstruction, infection, or opacification quantification); (2) Create verification checklist for ESS cases requiring documentation of failed conservative treatment (minimum 5-7 days antibiotics if bacterial infection suspected AND 6 weeks intranasal corticosteroids); (3) For chronic rhinosinusitis cases (CRSwNP and CRSsNP), verify 12+ continuous weeks of symptoms in medical record before authorizing; (4) For recurrent acute rhinosinusitis (RARS), confirm 4+ documented episodes within 12 months with complete symptom resolution between episodes; (5) For revision ESS, confirm at least 12 weeks since prior surgery and at least one 5-7 day antibiotic course post-prior ESS; (6) For balloon sinuplasty, ensure cases meet uncomplicated sinusitis criteria without nasal polyposis or fungal debris; (7) For image-guided ESS, limit authorization to specified indications (neoplasms, CSF rhinorrhea, skull base disease, distorted anatomy, sino-nasal polyposis, revision surgery, or frontal/posterior ethmoid/sphenoid involvement); (8) For post-operative debridement, authorize maximum 3 procedures within 6 weeks post-surgery unless clinical circumstances with supporting documentation justify additional procedures; (9) Deny post-operative debridement claims after simple nasal surgery (septoplasty, turbinectomy) or balloon sinuplasty. Providers must document in the CT report detailed descriptions of abnormal findings in each sinus, quantified opacification percentages, or Modified Lund-Mackay Scoring. Failure to obtain prior authorization with complete required documentation will result in claim denials. Update encounter templates and prior authorization forms in billing software to reflect these requirements.