CurrentIndependent HealthPolicy M20200928103

Corticosteroid-Eluting (Mometasone Furoate) Implants for the Treatment of Recurrent Nasal Polyps - Sinuva® and Propel®

Medical necessity criteria and coverage stance for Sinuva® and Propel® sinus implants for treatment of recurrent nasal polyps/chronic rhinosinusitis for Independent Health lines of business.

Policy Summary

PayerIndependent Health

PolicyCorticosteroid-Eluting (Mometasone Furoate) Implants for the Treatment of Recurrent Nasal Polyps - Sinuva® and Propel®

Policy CodePolicy M20200928103

Change TypeNo material change

Effective Date11/1/2020

Next Review Date

Key ActionObtain pre-authorization and document age, diagnosis of recurrent nasal polyps, prior ethmoid sinus surgery, persistent obstruction despite intranasal steroids, and prior trials or contraindications to listed therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum age for Sinuva coverage

90 daysSinuva drug release

30 daysPropel drug release

Pre-authAuthorization

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.

Coverage Criteria for Corticosteroid-Eluting Sinus Implants

Sinuva — Covered with criteria

Sinuva® is considered medically necessary when ALL of the following are met:

Sinuva medical necessity criteria: Member is ≥18 years of age.

Age requirement per FDA indication; documentation of age required.

Sinuva medical necessity criteria: Diagnosis of recurrent nasal polyps.

Diagnosis should be documented in the medical record.

Sinuva medical necessity criteria: History of ethmoid sinus surgery AND current nasal obstruction/congestion symptoms despite use of intranasal steroid irrigations or sprays.

Document prior ethmoid sinus surgery and persistent symptoms despite topical intranasal steroid therapy.

Sinuva medical necessity criteria: Prior treatment with, or documented contraindication or intolerance to, at least one of the following conventional nasal polyp therapies: leukotriene receptor antagonist, steroid taper, or intranasal steroids.

Specify which therapy was tried or the reason it was not tolerated/contradicted.

Propel — Investigational / Not covered

Propel® coverage stance

Propel investigational stance: Propel® (mometasone furoate sinus implant) for postoperative treatment following endoscopic sinus surgery or for treatment of recurrent chronic rhinosinusitis with or without sinonasal polyps is considered investigational based on available peer-reviewed evidence.

Not considered medically necessary per this policy; may be denied.

Sinuva® and Propel® are not medically appropriate for Child Health Plus members under the age of 18 because these devices have not been FDA-approved for individuals younger than 18 years.

Propel® (mometasone furoate sinus implant) is considered investigational and not medically necessary when used for postoperative treatment following endoscopic sinus surgery or for treatment of recurrent chronic rhinosinusitis, with or without sinonasal polyps, based on available peer‑reviewed evidence. Medicare Advantage and other specified lines follow the commercial criteria; coverage for Propel® is not supported by this policy for the indicated postoperative or recurrent CRS uses.

Referenced Billing and Coding

Referenced billing codesHCPCS

HCPCS C-code

CMS provides coverage for the HCPCS C-code assigned to this implant (unspecified in document)

Provider Actions, Requirements, and Denial Risks

Prior Authorization

Prior Authorization Required

Pre-authorization is required for Sinuva and related sinus implant services. Submit a prior authorization request before scheduling the procedure.

Prior authorization required for Sinuva (mometasone furoate sinus implant) and for Propel when billed as a postoperative implant procedure.

Step Therapy

Step therapy / Prior Treatments

Member must have tried and failed, or have a contraindication or intolerance to conventional nasal polyp therapies before Sinuva is covered. Document prior treatments and rationale for proceeding to implant therapy.

Required prior treatments include: leukotriene receptor antagonist, steroid taper, and intranasal steroids (or documented contraindication/intolerance).
Patient must have persistent nasal obstruction/congestion despite intranasal steroid irrigations or sprays.

Background

Chronic rhinosinusitis (CRS) is a prolonged inflammatory condition of the sinonasal mucosa that commonly presents with symptoms such as nasal obstruction/congestion, nasal discharge, facial pain or pressure, and decreased sense of smell. Management includes topical therapies (saline irrigations, intranasal steroid sprays or irrigations), systemic steroids or antibiotics when indicated, and endoscopic sinus surgery when medical therapy fails to restore ventilation and topical delivery. Implanted corticosteroid‑eluting devices are intended to provide local delivery of mometasone to ethmoid sinus regions; however, this policy distinguishes specific devices by indication and evidence: Sinuva® has defined coverage criteria while Propel® is considered investigational for postoperative use or treatment of recurrent CRS.

Definitions

Chronic rhinosinusitis definition

DefinitionChronic rhinosinusitis: inflammatory condition of the paranasal sinuses and nasal passages lasting ≥12 weeks; diagnosis requires objective evidence of mucosal inflammation.

Prevalence among CRS patientsApproximately 25–30% of patients with chronic rhinosinusitis have nasal polyps.

Key diagnostic requirementObjective evidence of mucosal inflammation (e.g., by CT or endoscopy) is required for diagnosis.

Nasal polyps definition

DefinitionNasal polyps: inflammatory outgrowths of sinonasal tissue occurring in an estimated 1–4% of the US general population.

Association with CRSAmong patients with chronic rhinosinusitis, about 25–30% have nasal polyps.

Policy Revision History

2026-01-01reviewedLatest

Policy reviewed by Health Care Services (signature/approval on file).

2025-01-01revised

Policy revised by Health Care Services.

2023-12-01revised

Policy Summary

PayerIndependent Health

PolicyCorticosteroid-Eluting (Mometasone Furoate) Implants for the Treatment of Recurrent Nasal Polyps - Sinuva® and Propel®

Policy CodePolicy M20200928103

Change TypeNo material change

Effective Date11/1/2020

Next Review Date

SourceLink

On This Page

Documentation Required

Required Documentation

Documentation must support age, diagnosis, prior surgery, persistent obstruction, and prior treatments or contraindications. Include operative report confirming prior ethmoid sinus surgery and clinical notes demonstrating persistent symptoms despite intranasal steroids.

Member age ≥ 18 years.
Diagnosis of recurrent nasal polyps.
Operative report confirming prior ethmoid sinus surgery.
Clinical documentation of persistent nasal obstruction/congestion despite intranasal steroid irrigations or sprays.
Documentation of prior treatments tried, or documented contraindications/intolerances to leukotriene receptor antagonists, steroid taper, and intranasal steroids.

Denial Risk

Denial Risks and Investigational Limits

Propel® (mometasone furoate sinus implant, Propel) is considered investigational for postoperative treatment following endoscopic sinus surgery or for treatment of recurrent chronic rhinosinusitis with or without sinonasal polyps and is therefore not covered. Sinuva coverage is limited to the specific criteria above.

Propel is investigational — grounds for denial if billed for postoperative treatment or recurrent CRS indication.
Sinuva coverage limited; claims not meeting the Sinuva criteria may be denied.

Clinical significanceRepresent inflammatory sinonasal tissue growths that can contribute to nasal obstruction and recurrent disease.

Sinuva® — product definition and indication

ProductSinuva® sinus implant: corticosteroid‑eluting implant delivering mometasone furoate; indicated for treatment of nasal polyps in patients ≥18 years who have had ethmoid sinus surgery.

Drug release durationReleases mometasone furoate locally over approximately 90 days (per clinical background).

Placement and removalPlaced in the ethmoid sinus; may be removed at physician discretion (bioabsorbable but distinct from Propel in duration).

Propel® — product definition and indication

ProductPropel® sinus device: a self‑expanding bioabsorbable stent formed of synthetic polymer in a lattice pattern, coated with mometasone furoate; used post‑operatively in the ethmoid sinus following endoscopic sinus surgery.

Drug release durationCoated with 370 micrograms of mometasone furoate released locally over a 30‑day period.

Absorption characteristicThe Propel implant dissolves over several weeks and does not require removal.

Policy revised by Health Care Services.

2022-12-01reviewed

Policy reviewed by Health Care Services.

2021-12-01reviewed

Policy reviewed by Health Care Services.

2021-01-01revised

Policy revised by Health Care Services.

2020-11-01effective

Policy effective date established.