CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Steroid-Eluting Sinus Stents Policy

Defines Blue Cross Blue Shield - Rhode Island coverage stance for steroid-eluting (drug-eluting) sinus stents used post-endoscopic sinus surgery or for recurrent sinonasal polyposis, including Medicare (BlueCHiP) and Commercial products, with coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySteroid-Eluting Sinus Stents Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 18, 2012

Next Review Date

Key ActionUse unlisted CPT code 31299 to report endoscopic placement of a drug-eluting implant in the ethmoid sinus when no other nasal/sinus endoscopic surgical services are provided; note that claims billed with J7401 or S1090 are not covered for BlueCHiP for Medicare and not medically necessary for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

2Primary non-covered indications listed

2Code entries listed

Coverage Summary

Defines Blue Cross Blue Shield - Rhode Island coverage stance for steroid-eluting (drug-eluting) sinus stents used post-endoscopic sinus surgery or for recurrent sinonasal polyposis, including BlueCHiP for Medicare and Commercial products; policy effective 09/18/2012, last reviewed 03/05/2020.

Coverage Determination / Medical Necessity

Coverage Determination

Coverage decisions for steroid-eluting sinus stents are based on available evidence and product indication:

For BlueCHiP for Medicare: The use of steroid-eluting sinus stents for postoperative treatment following endoscopic sinus surgery is not covered.

For BlueCHiP for Medicare: The use of steroid-eluting sinus stents for treatment of recurrent sinonasal polyposis following endoscopic sinus surgery is not covered.

For BlueCHiP for Medicare: The use of drug-eluting sinus stents is not covered in all other conditions.

For Commercial Products: The use of steroid-eluting sinus stents for postoperative treatment following endoscopic sinus surgery is not medically necessary.

For Commercial Products: The use of steroid-eluting/drug-eluting sinus stents is not medically necessary in all other conditions.

Not Covered / Not Medically Necessary

BlueCHiP for Medicare: steroid-eluting sinus stents are not covered for postoperative treatment following endoscopic sinus surgery and for treatment of recurrent sinonasal polyposis after ESS; the policy also states the use of drug-eluting sinus stents is not covered in all other conditions.

Commercial Products: steroid-eluting/drug-eluting sinus stents are not medically necessary for postoperative treatment following ESS and for all other conditions, with claims billed using device/drug codes to be denied for both Medicare and Commercial products.

Randomized controlled trials demonstrated some benefits on intermediate outcomes — reductions in need for postoperative intervention at 30 days and improvements in polyp grade/ethmoid obstruction — but the overall evidence is judged insufficient to determine effects on health outcomes, supporting the policy's non-coverage / not medically necessary determinations.

Coding Guidance

Not covered / Not medically necessary drug/device codesmixedNot Covered

J7401	Mometasone furoate sinus implant, 10 mcg (Effective 10/1/2019)
S1090	Mometasone furoate sinus implant, 370 micrograms. (Deleted 9/30/2019)

Procedure coding guidanceCPT

31299

Unlisted CPT code to report endoscopic placement of a drug-eluting implant in the ethmoid sinus without any other nasal/sinus endoscopic surgical services

Code S1090 was deleted 9/30/2019 and code J7401 is listed as effective 10/1/2019 per the coding section; when a drug-eluting implant is placed endoscopically without any other nasal/sinus endoscopic surgical services, the guidance is to report using unlisted CPT 31299.

Provider Actions & Billing Impact

Billing Rule

Use unlisted CPT when appropriate

To report endoscopic placement of a drug-eluting implant in the ethmoid sinus when no other nasal/sinus endoscopic surgical services are provided, use unlisted CPT code 31299.

31299

Denial Risk

Claims for noted implant codes will be denied / not covered

Claims billed with codes J7401 or S1090 are not covered for BlueCHiP for Medicare and are not medically necessary for Commercial products; reimbursement is not indicated.

J7401
S1090

Background and Device Details

Steroid-eluting sinus stents are bioabsorbable implants that maintain patency of sinus ostia and locally deliver the corticosteroid mometasone furoate over weeks to months.

Device families include the PROPEL system (bioabsorbable, self-expanding, releases steroid over approximately 30 days and dissolves so removal is not required) and SINUVA (a postoperative implant delivering 1350 μg mometasone furoate over 90 days and removed at Day 90 or earlier).

Device Definitions