Coverage of Conditions and Treatments (Coverage Decisions)

Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.

List also available in PDF format.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

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Imaging for Rhinosinusitis

Sinusitis is a condition characterized by inflammation of the lining of the paranasal sinuses. Rhinosinusitis is the preferred term for this condition because the nasal mucosa is simultaneously involved and sinusitis rarely occurs without concurrent rhinitis.

Conditions of Coverage:

  • Imaging with Sinus Computed Tomography (CT) is covered in the context of rhinosinusitis for the following:
    • Red Flags* OR
    • Persistent Symptoms** > 12 weeks AND failure of medical therapy; OR
    • Surgical planning.
    • Repeat scanning is not covered except for Red Flags or Surgical Planning.
  • Magnetic Resonance Imaging (MRI) of the sinus is covered in the context of rhinosinusitis for the following:
    • As above for sinus CT AND < 18 years of age OR pregnant.
  • Imaging of the sinus for rhinosinusitis using X-Ray OR Ultrasound is not covered.
    * Red Flags in the setting of Rhinosinusitis: (From American Academy of Otolarnygology-Head and Neck Surgery (AAO-HNS))
  • Swelling of orbit
  • Altered mental status
  • Neurological findings
  • Signs of meningeal irritation
  • Severe headache
  • Signs of intracranial complication, including, but not limited to:
    • Meningitis,
    • Intracerebral abscess
    • Cavernous sinus thrombosis
  • Involvement of nearby structures, including, but not limited to:
    • Periorbital cellulitis
      ** Persistent Symptoms are defined as ≥ two of the following: (From AAO-HNS)
  • Facial pain-pressure-fullness
  • Mucopurulent drainage
  • Nasal obstruction (congestion)
  • Decreased sense of smell

Implementation of the Coverage Decision

Imaging for rhinosinusitis may be used only for care of a condition accepted on the claim.