Medicare AdvantageCoverageHigh impact
Sinonasal and Eustachian Tube Surgical Procedures - Medicare Advantage (Revised)
Humana·ENT (Ear, Nose & Throat)·Medicare Advantage
Effective date
Apr 1, 2026
We identified it
Jul 28, 2026
Summary
Humana Medicare Advantage has revised its coverage policy for sinonasal and Eustachian tube surgical procedures, effective April 1, 2026. The policy establishes medical necessity criteria for BDET, balloon sinus ostial dilation, FESS, PNN ablation, and steroid-eluting sinus implants. Billing teams must ensure claims meet specific age, duration, diagnostic, and medical management requirements before submission to avoid denials.
Action Required
Before April 1, 2026: Billing team and ENT providers must implement verification requirements for all sinonasal and Eustachian tube procedures. (1) Update billing system to enforce age requirement (18+ years) for codes 69705, 69706, 31295-31298, and 31237-31288. (2) Add documentation checklists to encounter forms requiring: hearing evaluation, nasal endoscopic exam, otoscopic exam for BDET claims; failure of medical therapy documentation (steroids, antihistamines, antibiotics as applicable) and imaging (CT or nasal endoscopy) for balloon sinus dilation and FESS; abnormal diagnostic findings for all procedures. (3) Train providers to document chronic disease duration (≥12 weeks), specific symptoms, and all attempted medical management. (4) For balloon sinus ostial dilation adjunctively used during FESS in same sinus cavity—flag as integral and non-separately billable to prevent duplicate claims. (5) Create prior authorization workflow requiring submission of diagnostic imaging and documented medical management attempts. Failure to meet these criteria will result in claim denials by Humana Medicare Advantage.