Sinus Surgeries
Medicare Advantage Prior Authorization
Request Form — Fax: 866-874-0857
Harvard Pilgrim reserves the right to request additional clinical information.
Incomplete forms may delay response time.
Please check the box below only if request meets the definition of "expedited."
Expedited: Medicare defines expedited requests as those where “applying the standard time for
making a determination could seriously jeopardize the enrollee’s health, life, or ability to regain
maximum function.”
Patient Information
Person Completing Form
Patient name:
Name:
HPHC member ID #:
Phone #:
Date of birth:
Fax #:
Requesting Provider
Servicing Provider/Facility
Name:
Name:
HPHC provider ID #
Address
NPI #:
Date of service:
HPHC provider ID # (if known)
Diagnosis:
Tax ID #:
ICD-10 code:
Service type:
Inpatient
Outpatient
Number of visits/units requested:
Other
Service location:
Authorization type:
Procedure code(s) –– Check all codes that apply:
31254
31255
31256
31267
31276
31295
31296
If you have any questions about this process, please contact the Medicare Advantage Provider Service Center at
888-609-0692.
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MEDICARE ADVANTAGE PRIOR AUTHORIZATION REQUEST FORM (CON'T)
Sinus Surgeries
Click to view Harvard Pilgrim’s Medical Review Criteria for the Sinus Surgeries Policy.
Procedure
Frontal Sinusotomy
Maxillary Sinusotomy
Criteria (check all that apply)
Recurrent acute frontal rhinosinusitis, 4 or more episodes within 1 year
Mucocele or mucopyocele, CT confirmation required
Acute frontal rhinosinusitis, CT confirmation required
Primary immunodeficiency, or immunocompromise, including secondary to immunosuppressant medication
Focal neurological defect (e.g., weakness secondary to brain injury/
insult)
Facial or orbital cellulitis, or orbital or periorbital abscess, confirmed
by CT or Physical exam)
Intracranial abscess, cavernous sinus thrombosis, or osteomyelitis of
frontal bone, CT or MRI confirmation required
Meningitis (LP confirmed)
Pain that is severe, persistent and referable to frontal sinus disease
despite maximal medical treatment
Chronic frontal rhinosinusitis (symptoms present for >12 weeks):
CT confirms mucosal, or opacity
Symptoms have persisted after appropriate medical management:
Antibiotic therapy (if indicated and tolerated)
Intranasal corticosteroid spray
Contraindicated (rationale):
Acute maxillary rhinosinusitis: CT confirmation required
Primary immunodeficiency, or immunocompromise secondary to
immunosuppressant medication
Focal neurological defect (e.g., weakness secondary to brain injury/
insult)
Facial or orbital cellulitis, or orbital or periorbital abscess, confirmed
by CT or physical exam
Intracranial abscess, cavernous sinus thrombosis, CT or MRI confirmation required
Pain that is severe, persistent and referable to maxillary sinus despite
maximal medical therapy
Chronic maxillary rhinosinusitis, symptoms present for >12 weeks
CT confirms mucosal thickening, or opacity
Symptoms have persisted after appropriate medical management:
Antibiotic therapy and Intranasal corticosteroid spray
Contraindicated (rationale): ___________________________________
Fracture of orbital floor or malar eminence: CT or x-ray confirmation
required
Maxillary sinus mass: CT or MRI confirmation required
Recurrent acute maxillary rhinosinusitis, 4 or more episodes within 1 year
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MEDICARE ADVANTAGE PRIOR AUTHORIZATION REQUEST FORM (CON'T)
Sinus Surgeries
Functional Endoscopic
Sinus Surgery (FESS)
Chronic Polyposis, unresponsive to medical therapy
Sinus tumor
Recurrent sinusitis triggering or exacerbating existing pulmonary disease
Chronic sinusitis refractory to medical therapy
Antibiotic therapy and intranasal corticosteroid spray
Contraindicated (rationale):
Allergic fungal sinusitis with nasal polyposis, positive CT findings, and
eosinophilic mucus
Chronic sinusitis causing mucocele or cavernous sinus thrombosis
Suppurative (pus forming) complications including subperiosteal abscess
or brain abscess
Fungal mycetoma
Cerebrospinal fluid rhinorrhea
Encephalocele
Posterior epistaxis
Epistaxis related to severe septal deformity
Persistent facial pain
Uncomplicated sinusitis
Chronic sinusitis > 12 weeks duration that interferes with lifestyle
> 4 episodes of acute rhino sinusitis (less than 4 weeks duration) in
one year
Maximal medical therapy (i.e antibiotic therapy (if indicated and tolerated), trial of inhaled steroids if not contraindicated
Nasal lavage if tolerated, and allergy testing if appropriate)
CT suggestive of obstruction or infection nasal endoscopy suggestive of
significant disease
Physical exam suggestive of chronic/recurrent disease (e.g., mucopurulence, erythema, edema, inflammation)
Nasal or sinus cavity
Date of FESS ________________________
debridement following
Postoperative loss of vision or double vision
FESS
Cerebrospinal fluid leak (e.g., rhinorrhea)
(Procedure may be
Physical obstruction of the sinus opening related to:
authorized up to 4
Nasal polyps, unresponsive to oral or nasal steroids
times in the 30 days
Papilloma, carcinoma or other neoplasm
post FESS)
Allergic fungal sinusitis
Osteomyelitis of frontal bone
Synechiae formation (more than 4 may be necessary)
Describe previous treatments and outcomes, if applicable.
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MEDICARE ADVANTAGE PRIOR AUTHORIZATION REQUEST FORM (CON'T)
Sinus Surgeries
I attest that this form
has been completed
by me or my designee
and that all information is true and correct.
MD Name
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