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Medicare Advantage Prior Authorization
Nasal and Sinus Surgery

last updated 12/01/2009 garcarl

30120 Excision or surgical planing of skin of nose for rhinophyma 
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420 Rhinoplasty, primary; including major septal repair 
30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 
31020 Sinusotomy, maxillary (antrotomy); intranasal 
31030 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps 
31032 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps 
31040 Pterygomaxillary fossa surgery, any approach
31050 Sinusotomy, sphenoid, with or without biopsy; 
31051 Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) 
31070 Sinusotomy frontal; external, simple (trephine operation) 
31075 Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type)
31080 Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation)
31081 Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) 
31084 Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision 
31085 Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision 
31086 Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow incision 
31087 Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision 
31090 Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid)
31200 Ethmoidectomy; intranasal, anterior
31201 Ethmoidectomy; intranasal, total
31205 Ethmoidectomy; extranasal, total 
31225 Maxillectomy; without orbital exenteration 
31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 
31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection
31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) 
31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) 
31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy;
31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 
31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus 
31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; 
31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa
31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation)
31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation)
41512 Tongue base suspension, permanent suture technique 
42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 

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