CommercialCoverageMedium impact
Mometasone Furoate Sinus Implant (Sinuva) (CPB 0935, reviewed 2025-12-23)
Aetna·ENT (Ear, Nose & Throat)·Surgery
Effective date
Dec 23, 2025
We identified it
Aug 16, 2026
Summary
Aetna has updated its policy on Mometasone Furoate Sinus Implant (Sinuva) to establish medical necessity criteria for coverage. The procedure is now covered for patients 18+ years old with recurrent nasal polyps who have had prior ethmoid sinus surgery, have nasal obstruction symptoms despite intranasal steroid use, and would otherwise require revision surgery. Repeat administration is covered for patients with polyp grade ≥1 on either side.
Action Required
By December 23, 2025: Billing team must implement the following updates: (1) In the billing system, configure CPT codes 31254, 31255, 31257, and 31259 to require documentation of prior ethmoid sinus surgery, current nasal obstruction/congestion symptoms, and documented failure of intranasal steroid irrigations or sprays before claims are submitted for Aetna members. (2) Update claim submission logic to require HCPCS code J7402 to be billed only with ICD-10 codes J33.0-J33.9 (nasal polyp diagnoses). (3) Create or update prior authorization templates for Sinuva procedures to include verification of: patient age ≥18 years, prior ethmoid sinus surgery history, current symptom severity despite medical management, and candidate status for revision surgery. (4) Flag all claims for repeat Sinuva administration to require documentation of polyp grade ≥1 on endoscopy. (5) Update encounter forms and clinical documentation templates used by providers to capture these required elements. Failure to obtain proper prior authorization and documentation will result in claim denials from Aetna.