Is Balloon Sinuplasty Covered by My Insurance?

This is one of the first questions patients ask — and it is one of the most important, because cost uncertainty is one of the main reasons people delay getting care they need. Let me give you the clearest answer I can.

The Short Answer

Yes — balloon sinus dilation is covered by the vast majority of insurance plans in the United States, including Medicare, when the medical criteria for coverage are met. This is not a cosmetic procedure. It is a medically necessary treatment for chronic rhinosinusitis that has failed conservative management, and the major insurers recognize it as such.

Medicare

Traditional Medicare — Medicare Part B — covers balloon sinus dilation, Eustachian tube dilation, septal swell body reduction, the Neuromark procedure, and partial inferior submucosal turbinate reduction when Medicare is the primary insurance. Medicare Part B typically covers 80% of the Medicare-approved amount after your annual deductible is met. If you have a Medigap supplemental plan, it generally covers the remaining 20%.

Medicare Advantage plans are a different situation. These are private insurance plans that contract with Medicare, and coverage policies vary by plan. Most Medicare Advantage plans do cover these procedures — but the prior authorization process is more complex and approval is not automatic. Each plan has its own requirements and timelines. This is exactly why we have insurance specialists on staff — to navigate that authorization process on your behalf so you are not doing it alone.

All government insurance programs — Medicaid, TRICARE, VA — also cover balloon sinus dilation when medical criteria are met.

Major Commercial Insurers

Every major commercial insurance carrier covers balloon sinus dilation as a medically necessary procedure when documentation supports the diagnosis and treatment criteria. Here is a summary of what the major plans require:

Blue Cross Blue Shield covers balloon ostial dilation when the patient has documented chronic sinusitis, an abnormal CT scan of the paranasal sinuses showing radiographic evidence of persistent inflammation, and has failed appropriate medical management. BCBS updated its policy in 2025 and the coverage criteria are well-established.

Cigna covers balloon sinuplasty and Eustachian tube dilation with documented criteria including symptom duration of more than three months, appropriate CT findings, and failure of at least two full courses of antibiotics plus nasal steroid spray and saline irrigation.

Aetna covers the procedure as medically necessary for chronic rhinosinusitis of the frontal, maxillary, and sphenoid sinuses with documented disease persisting 12 weeks or longer and failure of medical management.

UnitedHealthcare covers balloon sinus dilation with relatively accessible criteria — documented sinusitis and trial of nasal lavage or appropriate medical therapy. United’s criteria are generally among the more straightforward to satisfy.

Humana covers balloon sinuplasty along with the other major procedures when medical necessity criteria are met and documentation is in order.

One important note: all of these plans require prior authorization for in-office procedures. That means the insurance company must approve the procedure before it is performed. We handle this authorization process for you through our dedicated authorization team.

What Determines Whether You Are Covered

Coverage is not based on which procedure you want — it is based on whether your clinical picture meets the criteria your insurer has defined. The documentation that supports a coverage approval typically includes your symptom history and duration, the results of your nasal endoscopy, your CT scan findings, and the treatments you have already tried. This is why the evaluation we do before any procedure discussion is not bureaucratic — it is the clinical foundation that establishes medical necessity.

The general criteria across carriers look like this: chronic sinus symptoms lasting 12 weeks or longer, CT imaging confirming sinus disease, and failure of appropriate medical management including nasal saline irrigation, nasal corticosteroid spray, and in most cases at least one course of antibiotics. If you have been living with chronic sinusitis for months or years and have been through the standard treatment cycle without lasting relief, you are likely in the range of criteria these plans require.

How to Find Out What Your Specific Plan Covers

The most direct path is to call us. When you schedule your appointment, give us your insurance information and our insurance specialists will verify your benefits, identify any authorization requirements, and clarify your estimated out-of-pocket costs before you ever come in. You do not need to navigate this alone.

If you want to do your own research before calling, here is exactly what to do: call the member services number on the back of your insurance card and ask specifically about coverage for balloon sinus ostial dilation — the clinical term insurers use — CPT codes 31295, 31296, 31297 and 31298. Ask whether prior authorization is required, what the medical necessity criteria are, and what your in-office specialist visit cost-sharing looks like.

You can also log into your insurer’s member portal and search for balloon sinuplasty or balloon ostial dilation in their coverage policies. Most major carriers publish their medical necessity criteria publicly.

Do not stress over this. It is our job to handle the insurance side. We have a dedicated division within our parent company specifically focused on insurance authorizations. Your job is to get evaluated and find out whether this procedure is right for you. Let us handle the rest.

Why In-Office Matters for Your Costs

One significant financial advantage of having these procedures performed in our office rather than a hospital or surgical center is the absence of facility fees and separate anesthesiologist charges. Traditional FESS performed in a hospital setting generates a surgeon fee, a facility fee, and an anesthesia fee — three separate cost components, each with their own deductible and co-insurance implications. In-office balloon sinus dilation under local anesthesia at SAWC involves one procedure, one setting, and typically a significantly lower total out-of-pocket cost for the patient.

Want to Understand More?

This post is part of the Why Sinus Treatments Fail — And What Starts Before Them series on the Airway & Sinus Wellness Review.

→ Does Balloon Sinuplasty Actually Work?

→ Is Balloon Sinuplasty Painful?

→ Is the Combination Procedure Too Much at Once?

Airway & Sinus Wellness Review — Full Publication

This post is part of the Why Sinus Treatments Fail — And What Starts Before Them section of the Airway & Sinus Wellness Review.

About the Author

Dr. Franklyn R. Gergits, DO, MBA, FAOCO is an otolaryngologist and rhinologist with over 30 years of clinical experience treating sinus and airway disease. He is the founder of the Sinus & Allergy Wellness Center of North Scottsdale and performed the first balloon sinuplasty in Pennsylvania. He holds dual Entellus Centers of Excellence certifications and specializes in office-based nasal and sinus procedures under local anesthesia. Dr. Gergits is the originator of the Posterior Sinonasal Syndrome (PSS) hypothesis — a clinical framework identifying posterior nasal mucosal inflammation driven by pepsin and laryngopharyngeal reflux as an etiological precursor to chronic rhinosinusitis. His hypothesis manuscript is currently under peer review, with a preprint available at Preprints.org (DOI: https://doi.org/10.20944/preprints202603.0858.v1). ORCID: 0009-0000-4893-6332.

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This content is for educational purposes only and does not constitute medical advice or a guarantee of insurance coverage. Coverage determinations depend on your specific plan, medical documentation, and insurer criteria. Contact SAWC or your insurance carrier directly to verify your individual benefits.