Investigational use may lead to claim denial

Claims for steroid‑eluting sinus stents and implants used postoperatively following endoscopic sinus surgery or for treatment of recurrent sinonasal polyposis may be denied because the policy states these uses are investigational and insufficient evidence exists to support health‑outcome benefits.

• Check member benefit and medical necessity before submission; investigational status may result in claim denial.

Procedure codes for placement are investigational and not covered

Placement of sinus stents and implants is listed as investigational and therefore not covered; procedure codes used to report placement are considered investigational and claims using those codes may be denied.

• Prior authorization will not convert investigational uses to covered services.
• Verify product applicability and member benefit before billing — coding alone does not imply coverage.

Check product/program applicability before authorization

Verify product- and program-specific applicability (including special programs such as FEP PPO) and the member's benefit plan before requesting authorization or scheduling the procedure.

Investigational procedure coding — implications for prior authorization

Procedure codes for steroid-eluting sinus stents/implants are listed in the policy coding section and placement is investigational; prior authorization will not convert investigational uses into covered services and claims may be denied.

• Policy coding listing does not denote coverage.
• Prior authorization cannot make an investigational procedure covered.

Postoperative treatment alternatives to stents/implants

Use conservative postoperative treatments that are supported by the evidence prior to considering implantable stents: options include saline irrigation, topical nasal steroid spray, and sinus cavity debridement; the optimal regimen is uncertain.

• Saline irrigation
• Topical nasal steroid spray
• Sinus cavity debridement
• Other options noted: nasal packs, systemic steroids, topical decongestants, oral antibiotics

Document indication and prior treatments for requests

Confirm and document the specific medical indication and that any requested service aligns with policy definitions and investigational stance; ensure all requests reference the member's diagnosis and prior treatments.

Verify member product applicability and program guidance

Verify the member’s product applicability and benefits (this policy applies only to certain programs and products administered by Capital Blue); check program-specific guidance (for example, FEP PPO refers to the FEP Medical Policy Manual) before providing services.

Ensure coverage contingent on member benefit and medical necessity

Confirm member benefit eligibility and medical necessity before billing; the presence of a code in the coding section does not by itself indicate coverage and services must be medically necessary per the member's benefit terms.