Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)AmeriHealth Caritas drug-eluting sinus implants Co…
    Ask Trek AI about this page
    CurrentAmeriHealth CaritasPolicy CCP.1310

    Drug-eluting sinus implants

    Customize your policy alerts

    Sign up for AmeriHealth Caritas Policy CCP.1310 alerts

    Get alerted when Policy CCP.1310 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines medical necessity and coverage criteria for drug-eluting sinus implants (e.g., PROPEL, Sinuva) following endoscopic sinus surgery for chronic rhinosinusitis for AmeriHealth Caritas members.

    Policy Summary
    PayerAmeriHealth Caritas
    PolicyDrug-eluting sinus implants
    Policy CodePolicy CCP.1310
    Change TypeCoverage stance revised to medically necessaryeligibility and contraindications clarified
    Effective DateJul 1, 2023
    Last ReviewJul 1, 2025
    Next Review DateNov 1, 20269d
    Key ActionObtain prior authorization demonstrating device placement after endoscopic sinus surgery and that all coverage criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage stance changed to medically necessary based on guideline recommendations and a new systematic review.

    Specified patient eligibility criteria including age ≥18, candidate for revision surgery, persistent nasal obstruction despite intranasal steroids, and no contraindications.

    Explicit contraindications listed including insulin-dependent diabetes, oral steroid–dependent conditions, glaucoma/ocular hypertension/posterior subcapsular cataracts, middle turbinate resection, acute bacterial or invasive fungal sinusitis, and corticosteroid allergy.

    18+minimum patient age for coverage
    90 daysSinuva steroid release duration

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    30 days
    PROPEL steroid release duration
    29 studiessystematic review evidence base
    7/2024coverage changed to medically necessary

    Coverage Criteria

    Initial coverage criteria

    Covered when ALL of the following are met:

    Age: Member is 18 years of age or older.>=18 years
    Surgical candidacy: Member is a candidate for revision endoscopic sinus surgery.

    Policy specifies candidate for revision endoscopic sinus surgery.

    Prior therapy: Member has persistent nasal obstruction/congestion despite use of intranasal steroid irrigations or sprays.failed intranasal steroid therapy

    Documented trial and inadequate response to intranasal steroid irrigations or sprays is required before implant placement.

    Contraindications absent: Member has no contraindications to drug-eluting sinus implants.

    Contraindications include insulin-dependent diabetes; oral steroid–dependent conditions; glaucoma, ocular hypertension, or posterior subcapsular cataracts; prior middle turbinate resection; acute bacterial or invasive fungal sinusitis; and corticosteroid allergy/intolerance.

    All uses of drug-eluting sinus implants that are not specifically described as covered in this policy are considered investigational and not medically necessary. This includes indications outside the postoperative setting following endoscopic sinus surgery and any applications that lack clinical evidence of benefit.

    Placement of a drug‑eluting sinus stent more than once in the same patient (repeat stent implantation) is expressly considered investigational and not medically necessary. Repeat implantation and other unlisted indications may be denied because they are not clinically proven.

    Provider Actions & Requirements

    Prior Authorization

    Prior authorization required for drug‑eluting sinus implants

    Prior authorization is required and must demonstrate the device is placed following endoscopic sinus surgery and that all coverage criteria are met, including patient age (≥18 years), candidacy for revision endoscopic sinus surgery, documented failure of intranasal steroid therapy, and absence of contraindications.

    Step Therapy

    Conservative therapy requirement — failed intranasal steroid therapy

    Document a trial and inadequate response to intranasal steroid irrigations or sprays prior to implant placement; coverage requires persistent nasal obstruction/congestion despite use of these therapies.

    • Record type of intranasal steroid used (irrigation or spray) and duration of trial.
    • Document persistent symptoms despite that therapy.

    Background

    Chronic rhinosinusitis is inflammation of the nasal and paranasal sinus mucosa; some patients require endoscopic sinus surgery to restore ventilation and drainage. Postoperative concerns include mucosal inflammation, polyp recurrence, adhesions, and impaired healing that can compromise surgical outcomes. Drug‑eluting sinus implants are designed to provide localized, controlled corticosteroid delivery into the surgical site to reduce edema, stabilize anatomy, and potentially reduce the need for additional postoperative interventions.

    Definitions

    PROPEL — device details
    Device namePROPEL (bioabsorbable steroid-eluting sinus stent)
    Steroid and doseMometasone furoate, 370 μg total release
    Release durationApproximately 30 days
    VariantsPROPEL Mini; PROPEL Contour (approved as adjunct to frontal and maxillary sinus surgery)
    Indicated agePersons age 18 years and older
    Sinuva — implant details
    Device nameSinuva (mometasone furoate sinus implant)
    Policy Summary
    PayerAmeriHealth Caritas
    PolicyDrug-eluting sinus implants
    Policy CodePolicy CCP.1310
    Change TypeCoverage stance revised to medically necessaryeligibility and contraindications clarified
    Effective DateJul 1, 2023
    Last ReviewJul 1, 2025
    Next Review DateNov 1, 20269d
    Key ActionObtain prior authorization demonstrating device placement after endoscopic sinus surgery and that all coverage criteria are met.
    SourceLink
    On This Page
    Coverage CriteriaProvider Actions & RequirementsBackgroundDefinitions
    Documentation Required

    Required clinical documentation for medical necessity

    Clinical documentation must confirm the member is ≥18 years old, is a candidate for revision endoscopic sinus surgery, has persistent nasal obstruction/congestion despite intranasal steroid irrigations or sprays, and has no contraindications to drug‑eluting sinus implants.

    • Patient age (≥18 years).
    • Statement of candidacy for revision endoscopic sinus surgery.
    • Documentation of trial and inadequate response to intranasal steroid irrigations or sprays.
    • Documentation that none of the listed contraindications are present (see policy).
    Denial Risk

    Investigational uses (including repeat implantation) are not covered

    Use of drug‑eluting sinus implants for indications other than following endoscopic sinus surgery (including repeat stent implantation) is investigational/not medically necessary and may be denied.

    • Repeat stent implantation and other unlisted indications are considered investigational and not medically necessary.
    Steroid and doseMometasone furoate, 1,350 μg dose
    Release durationApproximately 90 days; implant softens over this period
    Removal requirementImplant must be surgically removed after it softens
    Indicated agePatients at least 18 years of age (post-ethmoid sinus surgery)