CurrentCommunity-CarePolicy N/A

Mometasone sinus implant (Sinuva) — Coverage Criteria

This medical benefit medication utilization policy governs initial and continuation coverage criteria, quantity limits, authorization periods, and applicable billing codes for mometasone sinus implant (Sinuva) for members with chronic rhinosinusitis with nasal polyps; it affects providers (particularly otolaryngologists/ENTs) and covered members under Community-Care.

Policy Summary

PayerCommunity-Care

PolicyMometasone sinus implant (Sinuva) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 1, 2024

Key ActionSubmit prior authorization with ENT prescription, diagnosis of chronic rhinosinusitis with nasal polyps, evidence of prior ethmoid sinus surgery and failure of ≥1 corticosteroid nasal spray.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥1failed corticosteroid sprays

up to 2implants authorized per 90 days

90initial authorization (days)

1 yrcontinuation authorization

J7402HCPCS

Coverage Criteria for Mometasone Sinus Implant (Sinuva)

Initial Therapy

Covered when ALL of the following are met for initial approval:

Initial Approval for Sinuva: Prescribed by an otolaryngologist/ear nose throat (ENT).

From Initial Approval section

Initial Approval for Sinuva: Diagnosis of chronic rhinosinusitis with nasal polyps.

From Initial Approval section

Initial Approval for Sinuva: Had prior ethmoid sinus surgery for nasal polyps.

From Initial Approval section

Initial Approval for Sinuva:

Policy Summary

PayerCommunity-Care

PolicyMometasone sinus implant (Sinuva) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 1, 2024

SourceLink

On This Page

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.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for mometasone sinus implant (Sinuva) for chronic rhinosinusitis with nasal polyps. Requests must meet the payer's clinical criteria for initial approval (see criteria) before authorization will be granted.

Prior authorization required for initial and continuation therapy
Authorization decisions based on documented ENT prescription, diagnosis, prior ethmoid sinus surgery, candidacy for repeat surgery, and steroid spray trial
If approved, initial authorization up to 90 days; continuation up to 1 year

Step Therapy

Step Therapy Requirement

Step therapy requires failure of at least one corticosteroid nasal spray for the treatment of the current nasal polyps prior to initial approval.

Must document failure of ≥ 1 corticosteroid nasal spray for current nasal polyps

Documentation Required

Required Documentation

Submit clinical documentation with the prior authorization request to demonstrate that coverage criteria are met.

Prescription and consultation from an otolaryngologist/ENT
Diagnosis of chronic rhinosinusitis with nasal polyps (ICD-10 code as applicable)
Documentation of prior ethmoid sinus surgery for nasal polyps
Statement that the patient is a candidate for repeat sinus surgery
Documentation of failure of ≥ 1 corticosteroid nasal spray for current nasal polyps
For continuation requests: documentation of clinical benefit from prior mometasone sinus implant (Sinuva) use

Denial Risk

Potential Denial Triggers

Requests missing required elements are at high risk for denial. Review submitted documentation carefully before requesting authorization.

Denial likely if not prescribed by an ENT
Denial if diagnosis of chronic rhinosinusitis with nasal polyps is not documented
Denial if no prior ethmoid sinus surgery is documented (for initial therapy)
Denial if failure of ≥ 1 corticosteroid nasal spray is not documented
Denial if no documentation of candidacy for repeat sinus surgery
Denial for continuation if no evidence of prior benefit from Sinuva

Definitions and Device Details

Sinuva (mometasone furoate sinus implant) — product details

Generic nameMometasone furoate sinus implant

Brand nameSinuva

Dosage description10 micrograms per implant

Route and placementLocally placed in the ethmoid sinus outflow tract as a steroid implant

Applicable HCPCS codeJ7402 — Mometasone furoate sinus implant, (Sinuva), 10 micrograms

Prior ethmoid sinus surgery — definition

DefinitionPrior ethmoid sinus surgery: previous surgical intervention in the ethmoid sinuses for nasal polyps, required for initial approval of Sinuva

Role in criteriaMust have had prior ethmoid sinus surgery for nasal polyps as part of initial coverage determination

DocumentationClinical records should document prior ethmoid sinus surgery for nasal polyps when submitting prior authorization

OpenPayer

Mometasone sinus implant (Sinuva) — Coverage Criteria

Coverage Criteria for Mometasone Sinus Implant (Sinuva)

Applicable Codes and Coding Notes

Provider Requirements, Prior Authorization, and Documentation

Definitions and Device Details

Clinical Background