Mometasone Furoate (Sinuva) sinus implant coverage
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Defines Centene's medical necessity criteria, prior authorization requirements, and coverage limits for Sinuva (mometasone furoate sinus implant) for treating chronic rhinosinusitis with nasal polyps in adults, affecting providers submitting requests to Centene-affiliated health plans.
Step therapy bypass for Illinois HIM requests was added per IL HB 5395.
ICHRA (health insurance marketplace/ICHRA) was added as a line of business.
Coverage Criteria for Sinuva (mometasone furoate sinus implant)
Initial Approval — Chronic Rhinosinusitis with Nasal Polyps
Covered when ALL of the following are met:
Continued Therapy — Chronic Rhinosinusitis with Nasal Polyps
Covered when ALL of the following are met:
Other diagnoses/indications
For uses not specified in the main criteria:
Non‑FDA indications: Uses of Sinuva that are not included in the FDA‑approved labeling and are not specifically addressed in this policy are not authorized unless the provider supplies sufficient documentation of efficacy and safety in accordance with the applicable off‑label use policy for the member's line of business (see CP.CPA.09 for Commercial, HIM.PA.154 for Health Insurance Marketplace/ICHRA, or CP.PMN.53 for Medicaid).
Coverage and payment for Sinuva are subject to the terms, conditions, exclusions, and limitations contained in the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract) and to applicable Health Plan‑level administrative policies and procedures. This clinical policy is a guide to medical necessity and does not guarantee payment; providers must follow the member's benefit documents and Health Plan administrative requirements when submitting prior authorization requests or claims.
Requests for Sinuva for indications that are not FDA‑approved and are not addressed by this policy will be considered not authorized unless the provider submits sufficient documentation of efficacy and safety consistent with the applicable off‑label use policy referenced for the member's line of business (CP.CPA.09, HIM.PA.154, or CP.PMN.53). Absent that documentation, the use is considered not medically necessary.
Coding and Dose Limits
| J7402 | Mometasone furoate sinus implant, (Sinuva), 10 mcg |
Provider Actions, Authorization, and Documentation
Prior authorization required for Sinuva (J7402)
Prior authorization is required for Sinuva (HCPCS J7402). Sinuva is considered medically necessary only when the initial approval criteria are met; approvals are granted for 4 months (one implant per sinus).
- HCPCS J7402 — Mometasone furoate sinus implant, (Sinuva), 10 mcg
- Approval duration: 4 months (1 implant per sinus)
Prior authorization governed by Health Plan
Prior authorization requirements and coverage determinations are governed by the Health Plan's policies and the member's benefit documents; the Health Plan determines the effective date and may change or withdraw this clinical policy.
- Coverage decisions are subject to the member's coverage documents, state and federal requirements, and applicable Health Plan administrative policies and procedures.
PRIOR AUTH / STEP THERAPY — required intranasal steroid trials
Prior failure of specified intranasal steroid therapies is required before Sinuva unless contraindicated or adverse effects are documented; Illinois HIM requests are exempt from these step therapy requirements per IL HB 5395 effective 1/1/2026.
- Required prior therapies: mometasone nasal spray; Xhance®; one additional formulary intranasal steroid (e.g., budesonide).
- Illinois HIM requests bypass step therapy requirements as of 1/1/2026 per IL HB 5395.
Provider actions required for PA submission
Submit prior authorization requests with documentation showing the member meets all specified criteria, including diagnosis, age, prescriber specialty, prior ethmoid sinus surgery, required prior therapies or documented justification, intended inserter, and dosing limits.
- Confirm diagnosis of CRSwNP and age ≥ 18 years.
- Document otolaryngologist involvement and that member has had ethmoid sinus surgery.
- Provide evidence of prior trials or clinical justification if step therapy was not followed, and planned inserter (otolaryngologist).
- Indicate dose will not exceed 1,350 mcg (1 implant) per sinus per 90 days.
Submit supporting clinical documentation with requests
Provider must submit documentation (such as office chart notes, lab results, or other clinical information) that the member meets all approval criteria when requesting prior authorization.
- Include clinical notes showing response to prior therapies, polyp grading, and surgical history.
- Attach any laboratory or imaging results that support diagnosis and eligibility.
Documentation & coverage basis — follow Health Plan policies
Follow Health Plan administrative policies and the member's coverage documents when submitting requests or claims; this policy is a guide and does not guarantee payment.
- Adhere to the Health Plan's submission procedures, effective dates, and any state or federal requirements.
Denial risk if required documentation is incomplete
Requests that lack documentation demonstrating the member meets ALL approval criteria (diagnosis of CRSwNP, age ≥18, otolaryngologist involvement, prior ethmoid sinus surgery, required prior trials or documented justification, insertion by an otolaryngologist, and dosing limits) may be denied.
- Missing evidence of prior therapy trials or clinical justification for bypass may lead to denial.
- Absence of documentation that insertion will be performed by an otolaryngologist or that patient had ethmoid sinus surgery risks denial.
Coverage decision dependencies — subject to member coverage and plan policies
Coverage decisions are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable Health Plan-level administrative policies and procedures; state and federal requirements take precedence if applicable.
- This clinical policy is a guide to medical necessity and does not constitute a contract or guarantee of payment.
- Check member-specific evidence of coverage and applicable state addendums.
Definitions
Background
Sinuva (mometasone furoate sinus implant) is a bioabsorbable, corticosteroid‑eluting sinus implant indicated for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) in adults who have undergone ethmoid sinus surgery. The implant is placed endoscopically in the ethmoid sinus, releases mometasone over approximately 90 days, and may be removed at or before day 90 at the physician's discretion.
Revision History and Policy Changes
Step therapy bypass for Illinois HIM requests was added per IL HB 5395 effective 1/1/2026.
ICHRA (individual coverage HRAs / ICHRA) was added as a line of business during the 3Q 2026 annual review.
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