CurrentBlue Cross Blue Shield - MassachusettsPolicy 800

Mometasone furoate sinus implant (Sinuva) and steroid-eluting sinus stents/implants

Defines medical necessity criteria for use of the mometasone furoate sinus implant (Sinuva) for recurrent nasal polyposis in adults and states investigational status for steroid-eluting sinus stents for postoperative use and other indications; includes prior authorization rules for inpatient procedures and outpatient PA guidance by product.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMometasone furoate sinus implant (Sinuva) and steroid-eluting sinus stents/implants

Policy CodePolicy 800

Change TypeAnnual review; coding clarification

Effective Date

Next Review Date

Key ActionPrecertification/preauthorization is required for all products if the procedure is performed inpatient; document age, recurrence of nasal polyposis, and that optimal medical therapy was attempted and failed.

SourceLink

POLICY UPDATE CHANGES

4/2026 Annual policy review; literature review through December 31, 2025; references added; policy statements unchanged.

9/2023 New medically necessary indications for Sinuva added.

1Covered device (Sinuva)

1Investigational device category (stents)

4ICD-10 diagnosis codes listed

Coverage Summary

Scope: Defines medical necessity criteria for the mometasone furoate sinus implant (Sinuva) for recurrent nasal polyposis in adults and states investigational status for steroid-eluting sinus stents for postoperative use and other indications; includes prior authorization rules for inpatient procedures and outpatient PA guidance by product. Policy Number: 800. Coverage stance: mixed.

Thresholds and Dates

Age>= 18 years

Topical and/or systemic corticosteroids duration>= 8 weeks

Saline nasal irrigation duration>= 8 consecutive weeks

DefinitionsOptimal medical therapy

Policy last review2026-04

Medical-Necessity Criteria

Medically Necessary - Mometasone furoate sinus implant (Sinuva)

Covered when ALL of the following are met:

ALL of the following

Individual is 18 and older>= 18 years
Documented recurrence of nasal polyposis
Optimal medical therapy attempted and failed, as indicated by ALL of:
- Allergy evaluation, education, and optimal treatment
- Maximal use of decongestants
- Topical and/or systemic corticosteroids for at least 8 weeks>= 8 weeks
- Saline nasal irrigation for at least 8 consecutive weeks>= 8 consecutive weeks
- Education on environment irritants including tobacco smoke

Optimal medical therapy includes allergy evaluation/education/treatment; maximal use of decongestants; topical and/or systemic corticosteroids for >= 8 weeks; saline nasal irrigation for >= 8 consecutive weeks; and education on environmental irritants including tobacco smoke. This therapy must be attempted and failed prior to Sinuva placement as part of the medical necessity criteria.

Not Medically Necessary / Investigational

Investigational / Not Medically Necessary

The following uses are considered investigational:

ANY of the following

Use of steroid-eluting sinus stents for postoperative treatment following endoscopic sinus surgery
Use of steroid-eluting sinus stents for treatment of recurrent sinonasal polyposis (except Sinuva as specified above)
Use of drug-eluting sinus stents in all other conditions

Investigational stance: Except for the specified medically necessary indication for the mometasone furoate sinus implant (Sinuva) for adults with recurrent nasal polyposis after optimal medical therapy has failed, the use of steroid-eluting sinus stents for postoperative treatment following endoscopic sinus surgery and for treatment of recurrent sinonasal polyposis is considered investigational. Drug-eluting sinus stents are also considered investigational in all other conditions.

Coding

Medically necessary HCPCS codes (Sinuva)HCPCSCovered

J7402

Mometasone furoate sinus implant, (sinuva), 10 micrograms

Investigational HCPCS codes (stents)HCPCSNot Covered

S1091

Stent, non-coronary, temporary, with delivery system (propel)

Applicable ICD-10 diagnosis codes when medical necessity criteria are metICD-10Covered

J33.0	Polyp of nasal cavity
J33.1	Polypoid sinus degeneration
J33.8	Other polyp of sinus
J33.9	Nasal polyp, unspecified

Provider Actions & Requirements

Prior Authorization

Inpatient prior authorization required

Precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

Prior Authorization

Outpatient prior authorization guidance

Prior authorization is not required for outpatient procedures for Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue, and Medicare PPO Blue.

Documentation Required

Document optimal medical therapy and recurrence

Provider must document age, recurrence of nasal polyposis, and evidence that optimal medical therapy was attempted and failed (all listed components).

Age: individual is 18 and older
Documented recurrence of nasal polyposis
Allergy evaluation, education, and optimal treatment
Maximal use of decongestants
Topical and/or systemic corticosteroids for at least 8 weeks
Saline nasal irrigation for at least 8 consecutive weeks
Education on environmental irritants including tobacco smoke

Background & Evidence

Background: Steroid-eluting sinus implants and stents are used to maintain sinus patency after endoscopic sinus surgery (ESS) and to deliver local corticosteroid therapy. Sinuva is a mometasone furoate sinus implant that is placed in an office setting by a physician, lasts approximately 90 days, and may be used as an alternative to revision ESS for adults with recurrent nasal polyposis who have failed optimal medical therapy. Randomized controlled trials have demonstrated improvements in polyp grade and ethmoid obstruction for steroid-eluting implants in the recurrent/persistent polyposis setting.

Evidence	Summary
AAO-HNS position	January 2023 position statement supports use of Sinuva in individuals who have undergone ESS.
RCT evidence	Two randomized controlled trials demonstrated improvements in polyp grade and ethmoid obstruction for steroid-eluting implants in recurrent/persistent polyposis after endoscopic sinus surgery; Sinuva is an implant placed in-office and lasts approximately 90 days.

Definitions

Optimal medical therapy: Includes allergy evaluation/education/treatment; maximal use of decongestants; topical and/or systemic corticosteroids for at least 8 weeks; saline nasal irrigation for at least 8 consecutive weeks; and education on environmental irritants including tobacco smoke.

Revision History

2026-04Annual policy reviewLatest

Annual policy review; literature review through December 31, 2025; references added; policy statements unchanged.

2023-09-01New medically necessary indications; coding clarification

New medically necessary indications for Sinuva added. Clarified coding information effective 9/1/2023.