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but results were not reported separately by diagnosis. The body of evidence is limited by the small number of patients studied, unblinded outcome assessment, lack of appropriate comparators, and heterogeneity in outcome measures used. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 5 10/2021 Policy criteria clarified to align with IFAR/EPOS guidelines for chronic rhinosinusitis. 10/1/2021. 5/2021 Policy updated with literature review through 2020; no references added. 4/2020 Policy updated with literature review through February 29, 2020; references added. 4/2019 BCBSA National medical policy review. Description, summary and references updated. Policy statements unchanged. 3/2018 BCBSMA Medical Policy Group - Allergy, ENT/Otolaryngology review. No changes to policy statements. 1/2018 Clarified coding information. 6/2017 Policy statements clarified from standalone balloon sinuplasty to office-based or outpatient hospital/ambulatory balloon sinuplasty. 6/1/2017. 5/2017 New medically necessary and investigational indications. Clarified coding information. Effective 5/1/2017. 10/2016 New references added from BCBSA National medical policy. 1/2016 New references added from BCBSA National medical policy. 11/2014 BCBSA National medical policy review. Policy statement edited to remove trademarked name. Effective 12/1/2014. 2/2014 New references added from BCBSA National medical policy. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements. 6/17/2011 New policy effective 6/17/2011 describing ongoing non-coverage. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. Apr 2015; 152(2 Suppl): S1-S39. PMID 25832968 2. Hathorn IF, Pace-Asciak P, Habib AR, et al. Randomized controlled trial: hybrid technique using balloon dilation of the frontal sinus drainage pathway. Int Forum Allergy Rhinol. Feb 2015; 5(2): 167- 73. PMID 25360863 3. Plaza G, Eisenberg G, Montojo J, et al. Balloon dilation of the frontal recess: a randomized clinical trial. Ann Otol Rhinol Laryngol. Aug 2011; 120(8): 511-8. PMID 21922974 4. Bizaki AJ, Taulu R, Numminen J, et al. Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomized clinical study. Rhinology. Dec 2014; 52(4): 300-5. PMID 25479206 5. Hopkins C, Browne JP, Slack R, et al. The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict?. Otolaryngol Head Neck Surg. Oct 2007; 137(4): 555-61. PMID 17903570 6. Greguric T, Trkulja V, Baudoin T, et al. Association between computed tomography findings and clinical symptoms in chronic rhinosinusitis with and without nasal polyps. Eur Arch Otorhinolaryngol. May 2017; 274(5): 2165-2173. PMID 28154930 7. Levy JM, Marino MJ, McCoul ED. Paranasal Sinus Balloon Catheter Dilation for Treatment of Chronic Rhinosinusitis: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. Jan 2016; 154(1): 33-40. PMID 26519456 8. Chandra RK, Kern RC, Cutler JL, et al. REMODEL larger cohort with long-term outcomes and metaanalysis of standalone balloon dilation studies. Laryngoscope. Jan 2016; 126(1): 44-50. PMID 26228589 9. Minni A, Dragonetti A, Sciuto A, et al. Use of balloon catheter dilation vs. traditional Description Functional endoscopic sinus surgery (FESS) is a minimally invasive technique in which sinus air cells and sinus ostia are opened using a rigid fiberoptic endoscope. Three factors are crucial in the normal physiologic functioning of the sinuses: a patent sinus ostia, normal mucociliary transport, and normal quantity and quality of secretions. Disruption of at least one of these factors can predispose a patient to inflammation and infection of the sinuses. FESS attempts to address the patency issue in patients with medically refractory chronic rhinosinusitis. FESS is moderately effective for the treatment of recurrent acute or chronic infective sinusitis, chronic polyposis, mucocele, recurrent sinusitis aggravating pulmonary disease, sinus cysts and tumors, and uncomplicated rhinosinusitis. It has not been proven as effective treatment for allergic rhinitis. The goal of FESS is to return the mucociliary drainage of the sinuses to normal function. The paranasal sinuses are maintained in a healthy state by ventilation through the individual ostia and by a mucociliary transport mechanism
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