Does C1726 require prior authorization?

No, C1726 does not require prior authorization (high confidence). Covered without prior authorization.

`C1726`, Catheter, balloon dilatation, non-vascular

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Pre-procedure CT scan of the sinuses is required prior to performing balloon dilation.
Documentation must include abnormal diagnostic findings: either CT findings (eg, air-fluid levels, air bubbles, mucosal thickening >3 mm, pansinusitis, diffuse opacification) documented by a formal independent radiologist report, or nasal endoscopy showing significant sinus ostial obstruction.
Prior to dilation, there must be inadequate response to maximal medical therapy including saline nasal irrigation/spray, two or more antibiotic courses or one prolonged course ≥21 days, and a trial of nasal steroids.
A sinus CT scan is required prior to performing balloon dilation.

I. Diagnostic Esophagogastroduodenoscopy (EGD) in Adults
EGD for diagnostic purposes for adults aged 18 years or older is consideredmedically necessaryforanyof the following indications:
Upper abdominal signs or symptoms:Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy (for example, proton pump inhibitors) for 2 months or more;orPersistent vomiting of unknown cause;orNew-onset dyspepsia in individuals 50 years of age or older;orUnexplained dysphagia or odynophagia;orSigns or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea;orPostoperative b [...]
Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy (for example, proton pump inhibitors) for 2 months or more;or
Persistent vomiting of unknown cause;or
New-onset dyspepsia in individuals 50 years of age or older;or

ANTHEM-CG-MED-59, Upper Gastrointestinal Endoscopy in Adults

ANTHEM-CG-SURG-73, Balloon Sinus Ostial Dilation

BCBSIL-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

BCBSMT-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

BCBSNM-SUR706.019, Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis

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