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Q: What kinds of coverage exist for balloon dilation?
A: There are 3 ways insurance covers balloon dilation:
- Covered: These insurers cover standalone balloon sinus dilation for appropriate patients. However, coverage and criteria can change—you NEED to confirm coverage prior to treatment with your insurer or physician based on your specific plan.
- Investigational or Not covered: Currently, this insurer does not cover stand alone balloon sinus dilation (CPT codes 31295, 31296, 31297) and considers the treatment investigational. However this may change shortly as insurers are reviewing new clinical data from a recent randomized trial that shows how stand alone balloon sinus dilation offers benefits compared to traditional sinus surgery.
- Undisclosed: The above insurer has not published whether they cover standalone balloon sinus dilation, or consider it investigational. You should contact your insurer directly for additional information. Reference CPT codes 31295, 31296, and 31297.
Q: What are my options if I’m not covered?
A: If an insurer indicates that balloon sinus dilation is investigational and not covered, you still may be able to receive the procedure and experience the benefits of balloon sinus dilation. To start, please speak with your doctor to determine if you are a good candidate for the balloon procedure. If so, ask the doctor to request a pre-authorization of the balloon procedure. The insurance company may initially deny the claim. However, if an insurer denies a claim for medical services patients may have the right to file an appeal to request reconsideration of the decision. Under the 2010 Affordable Care Act (ACA), all insurers are required to have an appeals process in place.
- Check to see whether the internal appeals and external review provisions apply to you
- Contact your plan or your state insurance regulator
Q: What does the appeals process involve?
A: If you are a patient and denied coverage, you have the right to file an appeal. If you are a physician, you have the option to file an appeal of an adverse determination on behalf of a patient.