Anthem Blue Cross ConnecticutCommercial Clinical Policy

SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency Form

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Effective Date

04/12/2023

Last Reviewed

02/16/2023

Original Document

  Reference



This document addresses drug-eluting devices placed within the sinuses for the purpose of maintaining sinus ostial patency or for the treatment of nasal polyps (for example, Propel®-brand Mometasone Furoate Implants and SINUVA™ [Intersect ENT, Inc., Menlo Park, CA]).

Note: Non-drug-eluting packing materials and dressings intended to prevent the formation of adhesions and promote hemostasis, including Nasopore and SINU-FOAM, are NOT addressed in this document.

Note: For information regarding other sinus and nasal-related treatments and procedures, please see:

  • CG-SURG-18 Septoplasty
  • CG-SURG-24 Functional Endoscopic Sinus Surgery (FESS)
  • CG-SURG-57 Diagnostic Nasal Endoscopy
  • CG-SURG-73 Balloon Sinus Ostial Dilation
  • MED.00091 Rhinophototherapy
  • SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation

Position Statement

Investigational and Not Medically Necessary:

The use of drug-eluting devices for maintaining sinus ostial patency or the treatment of nasal polyps is considered investigational and not medically necessary for all indications.

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