Mometasone furoate sinus implant (Sinuva) — CPB 0935 | AETNA Coverage Update

Aetna modified CPB 0935 for mometasone furoate sinus implant (Sinuva), effective January 5, 2026. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its Sinuva coverage policy under CPB 0935 in the Aetna system, adding explicit criteria for repeat administration using HCPCS code J7402. If your practice places sinus implants in post-surgical nasal polyp patients, this policy directly affects your reimbursement and prior authorization workflows. The update tightens the language around repeat dosing — and that's the part your billing team needs to get right before claims go out.

Aetna Sinuva Coverage Criteria and Medical Necessity Requirements 2026

The Aetna Sinuva coverage policy under CPB 0935 sets a layered medical necessity test. Every layer must be met, and a claim missing any one of them is a claim denial waiting to happen.

For initial placement, Aetna covers J7402 when all four of these conditions are true:

That fourth criterion is doing a lot of work. Documented failed medical management isn't optional — it's a coverage requirement. Your medical record needs to show the patient tried intranasal steroids and still has symptoms. If that documentation isn't in the chart, the claim won't hold up on audit.

For repeat administration, the standard is different and simpler. Aetna covers subsequent Sinuva implants when the member has ethmoid sinus polyps graded 1 or higher on any side. That's a low bar on paper — but your billing team still needs a polyp grade documented in the record. A physician note that says "polyps present" without a formal grade won't cut it.

This is where Sinuva billing gets complicated. The initial and repeat criteria are different enough that you need two separate documentation checklists — one for first placements, one for retreatment. If your team is using a single PA template for both, fix that now.

Prior authorization is standard for implantable drug-device products like Sinuva under most Aetna commercial plans. Confirm prior auth requirements with the specific plan before the procedure date. The medical necessity criteria above form the clinical basis for any prior auth request.

Aetna Sinuva Exclusions and Non-Covered Indications

Aetna's position is direct: Sinuva is experimental, investigational, or unproven for all indications not listed in the medical necessity criteria above. There's no gray zone here.

If a provider uses Sinuva outside the post-surgical recurrent nasal polyp context — say, as a first-line treatment or in a patient without prior ethmoid surgery — Aetna won't cover it. The policy cites insufficient evidence in peer-reviewed literature as the basis. Don't expect a successful appeal on off-label use without strong clinical support and a well-documented exception request.

Coverage Indications at a Glance

Aetna Sinuva Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Sinuva Under CPB 0935

HCPCS Codes — Covered When Selection Criteria Are Met

J7402 is the only HCPCS code directly covered under CPB 0935. Bill this code for Sinuva placement — initial or repeat — when all applicable criteria are met and documented.

CPT Codes — Related Ethmoidectomy Procedures

These CPT codes are referenced in the policy as related procedures. They're not separately covered under CPB 0935, but they document the surgical history required to establish medical necessity for J7402.

When documenting prior surgical history for initial Sinuva placement, pull the operative report and confirm which of these codes was billed at the time of the original ethmoid surgery. Aetna's criteria require prior ethmoid sinus surgery — and your documentation needs to prove it with specificity.

Key ICD-10-CM Diagnosis Codes — Nasal Polyps

Use these J33 codes as the primary diagnosis when billing J7402. Confirm with your coder which subcategory applies to the specific polyp location and laterality documented in the operative note. Aetna's coverage policy ties medical necessity to nasal polyp diagnoses — using a non-specific or incorrect ICD-10 code creates unnecessary denial risk.