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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)Independent Health Sinuva Coverage Policy Update |…
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    CurrentIndependent HealthPolicy M20200928103

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

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    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
    Last ReviewJan 1, 2026
    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

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    90 daysSinuva drug release
    30 daysPropel drug release
    Pre-authAuthorization
    MultipleCovered lines

    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-codeCMS 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
    Last ReviewJan 1, 2026
    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
    On This Page
    Coverage Criteria for Corticosteroid-Eluting Sinus ImplantsReferenced Billing and CodingProvider Actions, Requirements, and Denial RisksBackgroundDefinitionsPolicy Revision History
    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.