CommercialCoverageMedium impact
Evaluation of Sinusitis (CPB 0694, reviewed 2025-12-29)
Aetna·ENT (Ear, Nose & Throat), Family Medicine, Internal Medicine +2 more·Medical Policy
Effective date
Dec 29, 2025
We identified it
Aug 14, 2026
Summary
Aetna has updated its Evaluation of Sinusitis policy (CPB 0694) to clarify that multiple advanced diagnostic tests and imaging modalities are considered experimental and not covered for sinusitis evaluation. Specifically, para-nasal sinus ultrasound (CPT 76536, HCPCS S9024), nasal nitric oxide measurement (CPT 95012), and various biomarker testing are now non-covered. Billing teams must immediately stop submitting claims for these procedures for sinusitis-related diagnoses.
Action Required
Immediately: Billing team must update denial logic in all billing systems to deny claims for CPT 76536 (soft tissue ultrasound of head/neck), CPT 95012 (nasal nitric oxide measurement), and HCPCS S9024 (paranasal sinus ultrasound) when billed with any acute sinusitis diagnosis code (J01.00-J01.91), chronic sinusitis diagnosis code (J32.0-J32.9), or CRS-related olfactory loss diagnosis code (R43.0). Configure system to append denial reason: 'Experimental/investigational per Aetna CPB 0694.' Notify all providers and clinical staff that these procedures are non-covered for sinusitis evaluation; providers should rely on clinical diagnosis and CT imaging (when medically necessary after 10 days of failed therapy) per policy guidance. Update encounter templates to reflect non-covered status. Any existing claims submitted for these codes with sinusitis diagnoses should be reviewed and corrected before adjudication to prevent denials.