Sinus Surgeries — CPB 0937 | AETNA Coverage Update

Aetna modified CPB 0937 covering endoscopic sinus surgery (ESS), effective January 11, 2026. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its sinus surgery coverage policy under CPB 0937 in Aetna's clinical policy bulletin system. This update affects 48 CPT codes and 21 HCPCS codes tied to ESS, balloon dilation procedures, and related sinus interventions — including CPT 31253, 31254, 31255, 31256, 31257, and 31259 for surgical endoscopy and CPT 31295, 31296, 31297, and 31298 for balloon sinus dilation. If your practice bills Aetna for ENT or sinus surgery work, this policy governs whether those claims pay or deny.

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Quick-Reference: Aetna CPB 0937 Sinus Surgery Policy Change 2026

Field	Detail
Payer	Aetna, a CVS Health company
Policy	Sinus Surgeries
Policy Code	CPB 0937
Change Type	Modified
Effective Date	January 11, 2026
Impact Level	High
Specialties Affected	Otolaryngology (ENT), Rhinology, Neurosurgery, Ophthalmology, Pediatric ENT
Key Action	Audit your ESS claims against the updated 17-indication medical necessity criteria before billing Aetna on or after January 11, 2026

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Aetna Sinus Surgery Coverage Criteria and Medical Necessity Requirements 2026

The core of this coverage policy is a 17-indication list. Every Aetna ESS claim must map to at least one. If it doesn't, expect a claim denial.

Aetna considers ESS medically necessary for chronic rhinosinusitis with nasal polyps (CRSwNP) only when symptoms have persisted longer than 12 continuous weeks, the patient has failed maximal medical treatment, and CT imaging confirms disease. Maximal medical treatment means at minimum five to seven days of antibiotics (if bacterial infection is suspected) and six weeks of intranasal corticosteroids. Document both — Aetna will look for them.

The same 12-week and maximal medical treatment bar applies to chronic rhinosinusitis without nasal polyps (CRSsNP). CT evidence is required here too. If your chart lacks a CT showing objective disease, this claim won't survive a medical necessity review.

Recurrent acute rhinosinusitis (RARS) has the most granular criteria in the policy. All three of the following must be met:

#	Covered Indication Copy
1	Four or more documented acute rhinosinusitis episodes within 12 continuous months, with complete symptom resolution between episodes
2	Episodes recurred despite maximal medical treatment, including intranasal corticosteroids during acute episodes plus antibiotics when bacterial infection was suspected
3	Objective evidence of outflow tract obstruction (not just narrowing) or sinus infection on CT imaging, or endoscopic evidence of rhinosinusitis documented during at least one acute episode

The dates of each episode and the treatments used must appear in the medical record. Aetna is explicit about this. Build a documentation checklist now, before the effective date.

Other covered indications include allergic fungal rhinosinusitis with CT evidence, antro-choanal polyp documented by CT, cerebrospinal fluid (CSF) rhinorrhea or skull base defect, complications of sinusitis (brain abscess, sub-periosteal abscess, orbital or skull base extension), endonasal endoscopic hypophysectomy for pituitary adenoma, endoscopic orbital decompression for Graves ophthalmopathy (CPT 31292 or 31293), para-nasal sinus mucocele on CT (excluding benign asymptomatic mucus retention cysts), silent sinus syndrome confirmed by endoscopy and orbital/paranasal CT, sino-nasal polyposis with airway obstruction or FEV1 below 80% despite maximal medical treatment, suspected or known sino-nasal tumor, and unilateral pansinus opacification.

Pediatric cases get their own criteria. For children up to age 12 with uncomplicated chronic rhinosinusitis, Aetna requires CT evidence of disease, failure of eight weeks of intranasal corticosteroids and three weeks of antibiotics, and failed adenoidectomy (CPT 42830, 42831, 42835, or 42836). All three boxes must be checked. If adenoidectomy hasn't been performed, ESS isn't covered under this indication.

Recurrent sinus barotrauma is covered when conservative management — oral decongestants, analgesics, and antibiotics for purulent discharge — has failed.

Regarding prior authorization: Aetna's CPB 0937 does not explicitly call out prior authorization requirements in the published bulletin criteria. However, for high-cost procedures like CPT 31253 (total ethmoidectomy with frontal sinus), CPT 31257, or CPT 31259, confirm prior auth requirements at the plan level before scheduling. Prior auth rules vary by Aetna product line and state. Don't assume the CPB tells the whole story on that.

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Aetna Sinus Surgery Exclusions and Non-Covered Indications

Three CPT codes are specifically excluded from coverage under CPB 0937:

#	Excluded Procedure Copy
1	CPT 31241 — Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery
2	CPT 31242 — With destruction by radiofrequency ablation, posterior nasal nerve
3	CPT 31243 — With destruction by cryoablation, posterior nasal nerve

Aetna does not cover posterior nasal nerve destruction (both radiofrequency ablation and cryoablation) or sphenopalatine artery ligation under this policy. These procedures appear in the code table under "CPT codes not covered if selection criteria are met." That language is a bit misleading — the point is that Aetna has carved them out entirely.

If your ENT team has been billing CPT 31242 or 31243 for chronic rhinitis management alongside sinus surgery, stop. Those claims won't pay under this policy, and retro-billing them creates audit exposure. Loop in your compliance officer if you've been billing these codes recently.

Para-nasal sinus mucoceles also have a specific carve-out: benign, asymptomatic mucus retention cysts are excluded. CT showing a retention cyst is not sufficient — the mucocele must be symptomatic to support a covered ESS claim.

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Coverage Indications at a Glance

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Aetna Sinus Surgery Billing Guidelines and Action Items 2026

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Sinus Surgery Under CPB 0937

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes Under CPB 0937

Code	Description	Reason Copy
31241	Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery	Not covered per CPB 0937 selection criteria
31242	Nasal/sinus endoscopy, surgical; with destruction by radiofrequency ablation, posterior nasal nerve	Not covered per CPB 0937 selection criteria
31243	Nasal/sinus endoscopy, surgical; with destruction by cryoablation, posterior nasal nerve	Not covered per CPB 0937 selection criteria

Key HCPCS Codes (Corticosteroid Injections — Related to CPB 0937)

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM list under CPB 0937 contains 321 codes. The complete list is available in the full policy document.

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