CurrentBlue Cross Blue Shield - MassachusettsPolicy 800

Mometasone furoate (Sinuva) sinus implant and steroid‑eluting sinus stents

Defines medical necessity and investigational uses for steroid‑eluting sinus implants (Sinuva) and other steroid‑eluting sinus stents for adults with recurrent nasal polyposis or postoperative care following endoscopic sinus surgery. Applies to Blue Cross Blue Shield of Massachusetts commercial and Medicare products as specified.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMometasone furoate (Sinuva) sinus implant and steroid‑eluting sinus stents

Policy CodePolicy 800

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain precertification/prior authorization when the procedure is performed inpatient and document prior failure of optimal medical therapy including ≥8 weeks of corticosteroids and saline irrigation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum patient age for Sinuva coverage

>=8 wksrequired steroid therapy duration

J7402medically necessary HCPCS

S1091investigational HCPCS

≈90 days

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

implant duration (approx)

Coverage Criteria

Medically Necessary: Sinuva (mometasone furoate sinus implant)

Covered when ALL of the following are met:

Age: Individual is 18 and older>=18 years

Prior optimal medical therapy: Optimal medical therapy has been attempted and failedsee therapies below

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

Clinical finding: Documented recurrence of nasal polyposisdocumented recurrence

Investigational / Not Covered

Postoperative steroid‑eluting stents for ESS: The use of steroid‑eluting sinus stents for postoperative treatment following endoscopic sinus surgery and for treatment of recurrent sinonasal polyposis is INVESTIGATIONAL

Policy states investigational for postoperative treatment and for recurrent sinonasal polyposis in general; however Sinuva is an identified product considered medically necessary when criteria met.

Other conditions: The use of drug‑eluting sinus stents is considered INVESTIGATIONAL in all other conditions

Drug‑eluting sinus stents (for example, HCPCS S1091 / Propel and other non‑covered stents) are considered investigational and not covered. The source policy explicitly states that “the use of drug‑eluting sinus stents is considered INVESTIGATIONAL in all other conditions,” and lists HCPCS S1091 (Propel) as a non‑covered device.

The use of steroid‑eluting sinus stents for postoperative treatment following endoscopic sinus surgery (ESS) and for treatment of recurrent sinonasal polyposis is labeled INVESTIGATIONAL. Although the policy identifies Sinuva (mometasone furoate sinus implant) as covered when specific criteria are met, steroid‑eluting stents in the postoperative setting and for recurrence of polyposis are not considered medically necessary under this policy.

Coding

Medically necessary HCPCS CodesHCPCSCovered

J7402

Mometasone furoate sinus implant (Sinuva) 10 micrograms

Investigational HCPCS CodesHCPCSNot Covered

S1091

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

Covered ICD-10 Diagnosis Codes (when criteria met)ICD-10

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

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Precertification / Prior Authorization — requirement and related guidance

Precertification/prior authorization is REQUIRED for services described in this policy when the procedure is performed inpatient for all products.
For outpatient services: Commercial PPO and Indemnity — prior authorization is NOT required; Medicare HMO BlueSM — prior authorization is NOT required; Medicare PPO BlueSM — prior authorization is NOT required.

Documentation Required

Required Documentation for Medical Necessity

Required documentation to support medical necessity must be provided at the time of prior authorization and/or upon request. Documentation should demonstrate all elements below.

Patient age: documentation that the individual is ≥ 18 years old.
Evidence of recurrent nasal polyposis (clinical notes, endoscopy findings, imaging, or operative reports).

Background

Chronic rhinosinusitis affects an estimated 1–5% of the U.S. population and may require endoscopic sinus surgery (ESS) when conservative measures fail. Postoperative inflammation, edema, and synechiae can impair surgical outcomes; implants and stents have been developed to help maintain sinus ostia patency, reduce edema, prevent adhesions, and deliver topical corticosteroid locally over an extended period.

This policy distinguishes between a specifically studied steroid‑eluting implant, Sinuva (mometasone furoate sinus implant), which may be considered medically necessary for adults meeting defined criteria, and other drug‑eluting or steroid‑eluting stents used for postoperative care or recurrent polyposis, which are labeled investigational.

Definitions

Steroid‑eluting sinus implant/stent — definition and intended effects

DefinitionAn implant placed in the sinus cavity to stabilize sinus openings and turbinates, reduce edema, prevent obstruction from adhesions, and/or deliver topical medication locally over an extended period.

Primary intended effectsMaintain patency of sinus openings postoperatively, reduce postoperative inflammation, and serve as a local drug‑delivery vehicle to improve sinus drainage and recovery and potentially reduce need for additional surgery.

Typical clinical settingUsed in the postoperative period following endoscopic sinus surgery (ESS) or for treatment of recurrent sinonasal polyposis after ESS.

Mechanism of actionMechanical stenting of sinus ostia combined with sustained local release of corticosteroid to reduce edema and polyp burden.

Duration of local therapyDesigned to deliver medication locally over an extended period while implant remains in place (Sinuva persists approximately 90 days).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMometasone furoate (Sinuva) sinus implant and steroid‑eluting sinus stents

Policy CodePolicy 800

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Documentation of allergy evaluation, patient education, and instruction on avoidance of environmental irritants including tobacco smoke.

Failure of optimal medical therapy, including at least all of the following: topical and/or systemic corticosteroids for at least 8 weeks, maximal use of decongestants, and saline nasal irrigation for at least 8 consecutive weeks.

Details of prior treatments and response (dates, doses, duration).

Any relevant allergy testing results and notes on medical management of allergic contributors.

For postoperative use or other indications, documentation that the use is consistent with policy criteria (note: steroid-eluting sinus stents for postoperative treatment following endoscopic sinus surgery and for treatment of recurrent sinonasal polyposis are considered INVESTIGATIONAL).

Sinuva (mometasone furoate sinus implant) — device description and intended use

Device descriptionSinuva (mometasone furoate sinus implant) is a steroid‑eluting sinus implant designed to be implanted in the ethmoid sinus to provide local mometasone delivery after endoscopic sinus surgery.

Intended useIn‑office treatment of recurrent nasal polyposis in adults who have previously undergone endoscopic sinus surgery (ESS).

Implantation setting and durationImplanted by a physician in an office setting and remains in place for approximately 90 days while eluting medication locally.

Clinical outcomes notedRandomized controlled trials demonstrated improvements in polyp grade, reduced nasal obstruction, and reduced need for repeat sinus surgery in the target population.

Guideline/position statementAAO‑HNS published an updated position statement (January 2023) supporting use of Sinuva in individuals who have undergone ESS.