Is Balloon Sinuplasty Covered By My Insurance?

Sinusitis is a disease of the sinuses and is a common problem that afflicts over 29 million Americans. The sinuses are cavities in the front of the skull around the nose region. They are lined with soft tissue that has a mucous membrane covering. Normally, the sinuses are open and air flows in and out of them. The mucus in them also drains down to an outlet at the back of the nasal passage.

What is Balloon Plasty?

If for whatever reason, the sinuses get blocked, then mucus piles up in the cavities instead of draining out. This trapped mucus could become the site for growth of bacteria, further compounding the problem. When a sinus problem does not go away despite treatment or if it keeps recurring, it is referred to as chronic sinusitis. The following symptoms could be an indicator of the disease:

  • Pain
  • Fever
  • Stuffiness
  • Sore throat
  • Cough
  • Discolored nasal discharge

Chronic sinusitis has a number of possible causes. This means that a myriad of factors can cause the lining of the sinus cavity to get inflamed. Some of these are:

  • Growths known as polyps within the nasal passage or sinus can block it
  • A bacterial or viral infection. These often cause flu or cold-like symptoms. Bacterial infections are treated using antibiotics while viral infections have no cure other than managing the symptoms.
  • Deviated septum-this refers to the wall of the nose that separates the nostrils. If it is not in its correct position, sinusitis might arise.
  • Allergen- these are, by far, the most common cause of sinusitis. Among the triggers of allergic reactions are; pollen, dust, smoke, dust mites, pet debar and chemicals in the air.
  • Some medications can also cause allergic reactions.

If your sinusitis lasts for more than 12 weeks, it is classified as chronic. This means that medical intervention is necessary. Depending on the severity of your condition and your medical history, the doctor can offer you a range of treatment options. Some might consist of medications while others will need surgical intervention.

While surgery might sound scary to some people, it might be the only option where your sinus problems are caused by a growth or some other physical barrier such as a deviated septum. Luckily, technology has seen the rise of medical procedures that are far more efficient while restricting the amount of cutting and suturing that was the trademark of traditional surgery. One such procedure is balloon plasty.

Balloon Sinuplasty Surgery Procedure

Balloon sinuplasty is also known as balloon catheter dilation surgery and is a modern surgical option that was given the green light by the Food and Drug Administration ( FDA) in 2005. It is often carried out when other options to treat chronic sinusitis have not been effective. What makes this procedure so attractive is that it does not involve cutting through bone or removing tissue. Despite this, it is still a surgical procedure with the attendant risks of any surgery.

Balloon sinuplasty can be carried out in a hospital or the office of an ENT specialist. It is advisable that you discuss the procedure with your doctor before the date it will be carried out. You can choose to have it done under local or general anesthesia. After you are numb, the doctor then inserts a wire up your nostril and into the sinus cavity. At the end is a small flashlight that enables the doctor to see what he is doing.

Next, the flexible tube that bears the balloon is inserted to go alongside the wire. Once the balloon is in place, it is inflated within the sinus cavity. This has the effect of opening up any obstruction within the sinus. The doctor also flushes out the mucus that has built up in the cavity by using a saline solution. By the time the balloon is deflated, it is expected that the structures around the sinus will have taken its new shape and the sinus will remain open. The healing time is usually a week or less. Your doctor also gives you instruction and medications to assist you to recover without complication.

Costs and Insurance

You can expect to pay between 3,000 and 7,000 dollars for your balloon sinuplasty, depending on your doctor. An office or clinic setting for your procedure will tend to be cheaper than if you have to be wheeled into the theater. Before you sign up for balloon sinuplasty, you should have decided where funding for the procedure will come from. One option that people go for is to use their health insurance.

There are various insurance plans that are on offer for balloon sinuplasty. The first one covers the procedure, although the criteria and extent of the coverage may differ from insurer to the next. For this reason, it is important that you discuss the payment guidelines offered by the company with both your doctor and the insurer. This should be done before the procedure is carried out.

An insurance company can place balloon sinuplasty under the medical procedures labeled investigational or not covered. This means the insurer does not recognize the procedure as being curative when it is carried out on its own. Rather, they view it as a process used to diagnose a medical condition and will not pay for it. However, this position is under review and could change at any time.

If an insurer has an undisclosed status against a particular medical procedure, it means that the company does not say whether they have covered that procedure or not in their plan. You, therefore, need to contact the insurance company before the surgery so that they can confirm their stand.

There is also a process that is followed to appeal a decision by an insurance company not to pay a medical claim like balloon sinuplasty. This is found in the 2010 Affordable Care Act (ACA), which requires every insurance company to have an appeal system in place. Under this provision, your claim could be reviewed and settled even if the initial claim was turned down.


Balloon sinuplasty is a safe and highly effective treatment that could change your life. If the doctor identifies that you are a perfect candidate for it, ensure that your insurance company provides the coverage needed. The Becker ENT center can guide you on the best treatment options since it has accredited doctors with the experience to restore your health. They can be contacted here.

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