CurrentAvMedPolicy Pub. 100-2

Mometasone sinus implants (Propel, Sinuva) — Coverage Criteria

Defines prior authorization and step-edit requirements for outpatient placement and coverage of mometasone sinus implants (Propel and Sinuva) for AvMed members; applies to prescribing clinicians and facilities requesting coverage.

Policy Summary

PayerAvMed

PolicyMometasone sinus implants (Propel, Sinuva) — Coverage Criteria

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with all required documentation and ensure member meets age and prior therapy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

one lifetimeimplantation approvals per sinus (lifetime)

>=18minimum member age for approval

2failed nasal corticosteroid trials required

1failed oral corticosteroid courses required

S1091, J7402HCPCS codes listed

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Approval criteria (initial)

Covered when ALL of the following are met

Primary approval criteria: Member is at least 18 years of age; administering physician is an Otolaryngologist (ENT); member has a diagnosis of recurrent nasal polyp disease; member has a history of sinonasal surgery; member has tried and failed TWO nasal corticosteroid sprays (e.g., fluticasone, budesonide, triamcinolone); member has tried and failed ONE full course of an oral corticosteroid (e.g., prednisone, methylprednisolone, dexamethasone).all

All criteria must be met and documented; approval is for one implantation per sinus per lifetime.

Member must be at least 18 years of age to meet coverage criteria for mometasone sinus implants. Requests for members younger than 18 do not satisfy the age requirement and are excluded from coverage.

The use of sample products to start therapy does not satisfy step-edit or prior authorization requirements. Prior therapies will be verified through pharmacy paid claims or submitted chart notes; documentation that treatment began with samples alone will not meet the prior therapy requirement for approval.

Provider Requirements and Submission Instructions

Prior Authorization

Prior authorization required for listed implants

Prior authorization is required for Propel (S1091) and Sinuva (J7402) sinus implants; all clinical criteria must be met and documented for approval. Approval is limited to one implantation per sinus per lifetime.

Codes: S1091 (Propel), J7402 (Sinuva)
All checklist criteria on the form must be met and supported with documentation (lab results, diagnostics, chart notes).

Step Therapy

Step-edit verification and samples

Previous therapies will be verified through pharmacy paid claims or submitted chart notes; use of samples does not satisfy step-edit or prior therapy requirements.

Document two failed nasal corticosteroid spray trials and one failed full course of an oral corticosteroid as specified on the clinical criteria checklist.

Documentation Required

Required submission elements

The prescriber must sign and clearly print their name (preprinted stamps not valid) and provide member and prescriber details, drug details, diagnosis/ICD code if applicable, dosing/length of therapy, and supporting documentation for each clinical criterion checked.

Member and prescriber information including Member AvMed #, DOB, prescriber name, NPI, office contact, phone and fax.
Drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight if applicable, date weight obtained.
Supporting documentation: lab results, diagnostics, chart notes for each checked criterion.

Denial Risk

Incomplete documentation or missing prior therapies

Authorization may be delayed or denied if the request is incomplete, incorrect, or illegible, or if supporting documentation for checked clinical criteria or prior therapy requirements is not provided.

Illegible or missing phone/fax/NPI or unsigned forms can delay authorization.
Failure to include lab results, diagnostics, or chart notes for each checked clinical criterion risks denial.

Background

Sinus steroid implants (Propel and Sinuva) are endoscopically placed by an otolaryngologist into the sinus cavity to provide local corticosteroid delivery over approximately 90 days. They are intended for members with recurrent nasal polyp disease who have a history of sinonasal surgery and who have failed prior medical therapy. Placement is performed under endoscopic visualization by a physician trained in otolaryngology; Sinuva may be removed at or before day 90 at the physician’s discretion. Approval is limited to one implantation per sinus per lifetime and all clinical criteria must be documented for prior authorization.

Definitions

Sinus implant administration

Administration methodPlaced in the sinus cavity under endoscopic visualization by a physician trained in otolaryngology

Duration of drug releaseMay be left to gradually release corticosteroid over approximately 90 days

Sinuva removal optionSinuva implants can be removed at day 90 or earlier at the physician's discretion using standard surgical instruments

Lifetime implantation limit

Lifetime implantation limitApproval is for one implantation per sinus per lifetime

Associated approval criteria noteAll clinical criteria must be met and documented; approval limited to one implantation per sinus per lifetime

Minimum age relevanceMember must be at least 18 years of age for approval under this lifetime limit