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Does Anthem Insurance Cover Sinus Surgery?

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Anthem insurance will cover sinus surgery when it is assessed and determined as a medically necessity. This includes any sort of condition that shows or has a possibility of showing serious damage to a patient’s health. Most often, sinus conditions are progressive and insurance companies will try a number of non-surgical treatments before deciding if sinus surgery is necessary.

Functional endoscopic sinus surgery is considered medically necessary for the treatment of sinusitis, polyposis, or sinus tumor when any one of the following circumstances are seen:

  • A Suspected tumor is present during imaging tests and/or physical examinations
  • Complications from endoscopy the forming of pus that include subperiosteal or brain abscess

If there is chronic polyposis that has symptoms shown to be unresponsive to medical therapy or allergic fungal sinusitis (often indicated with nasal polyposis, findings in the CT, mucus) Anthem considers this a medical concern and necessity of sinus surgery.

Also, if mucocele causing chronic sinusitis or recurrent sinusitis that triggers or aggravates pulmonary disease, such as asthma or cystic fibrosis, sinus surgery is suggested.

Uncomplicated sinusitis (siunitus that does not have any direct harm to other surrounding parts of the nasal or face) must accord to the following in order to be considered a medically necessary treatment:

Four or more documented episodes of acute rhinosinusitis in one year and chronic sinusitis that interferes with lifestyle.

Medical therapy has been attempted in various forms including

  • Antibiotic therapy for at least 4 weeks
  • Trial of inhaled steroids
  • Nasal lavage
  • Allergy testing

When these processes have proven unsuccessful, sinus surgery is often the next step.

Abnormal findings from diagnostic tests, as indicated by:

  • CT scans that show signs of obstruction or infection (air fluid levels, air bubbles, significant mucosal thickening, pansinusitus, etc)
  • Discovery of possibility of significant disease
  • Discovery of chronic or recurrent disease
  • Fungal mycetoma
  • Previously failed sinus surgery
  • Cerebrospinal fluid rhinorrhea
  • Encephalocele
  • Posterior epistaxis
  • Persistent facial pain unrelated to any of the previously mentioned symptoms
  • Cavernous thrombosis caused by chronic sinusitis

Sometimes, people will suffer conditions after having sinus surgery. If these post-op conditions meet the requirement for Anthem healthcare, they may consider a second surgery medically necessary. Some post-op complications might need nasal or sinus cavity debridement if:

  • The is postoperative vision obstruction or loss of vision
  • Evidence of a fluid leak
  • When physical obstruction of the sinus opening causes
  • Nasal polyps that has not changed with the use of oral or nasal steroids
  • Documented presence of papilloma, carcinoma or other neoplasms
  • Allergic fungal sinusitis

Anthem states that if the criteria of medically necessary sinus surgery is not met, than the procedure is considered cosmetic. Rhinoplasty (or a nose job) is almost always considered a cosmetic procedure, and will not be covered by Anthem. If you feel that you are suffering from sinus issues that might only be fixed with a cosmetic procedure, a medical consultation is performed to ensure that your health is indeed at risk.

The specifics of what is and is not covered by Anthem for sinus surgery is detailed and specific. If you have questions that pertain to your individual case that were not mentioned here, please call us at (855) 690-0565 to learn more about Anthem insurance and sinus surgery treatments.

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