HCPCS Level II › J codes J7402 Mometasone sinus sinuvaMometasone furoate sinus implant, (sinuva), 10 micrograms
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 270 units per day (clinical), rationale: Prescribing Information Outpatient hospital: max 270 units per day (clinical), rationale: Prescribing Information Medicare pricing for J7402 Medicare Part B drug payment limit (ASP, October 2026) J7402 payment limit: $11.345 per 10 MCG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%.
NDCs that bill under J7402 (CMS ASP NDC-HCPCS crosswalk, October 2026) 10599-0003-01 Sinuva, Intersect ENT, INC.: 135 billing units per package (1 POUCH in 1 CARTON / 1 IMPLANT in 1 POUCH)Physician Fee Schedule (CY 2026, RVU26D) Status E: excluded from the PFS by regulation.
Payer policies and prior authorization for J7402 39 of 39 payer prior-auth lists that name J7402 require prior authorization or set conditions: CarePlus Health Plans, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid), Passport by Molina Healthcare (Kentucky).
Payer Plan State Prior auth Conditions Since Source Cigna ACA/IFP All prior auth required Apr 1, 2021 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required Apr 1, 2021 Master Precertification List (For Health Care Providers) Cigna Complete/PHS+/Preferred All prior auth required Apr 1, 2021 Master Precertification List (For Health Care Providers) CarePlus Health Plans CarePlus Health Plans FL prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi Humana Humana D-SNP (FL) FL prior auth required Jul 1, 2026 H1036-280 Humana Fully Integrated Florida prior authorization and notification list Humana Humana D-SNP (IL) IL prior auth required Jan 1, 2027 Humana Dual Fully Integrated Illinois prior authorization and notification list Humana Humana D-SNP (IN) IN prior auth required Jan 1, 2027 Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: Humana Humana D-SNP (MI) MI prior auth required Oct 14, 2026 Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) Humana Humana D-SNP (SC) SC prior auth required Jul 1, 2026 Humana Dual Integrated South Carolina prior authorization and notification list Humana Humana D-SNP (VA) VA prior auth required Jul 1, 2026 Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) Humana Humana Healthy Horizons FL prior auth required Jan 1, 2027 Humana Healthy Horizons in Florida Prior Authorization and Notification List Humana Humana Healthy Horizons KY prior auth required Oct 7, 2026 Humana Healthy Horizons in Kentucky Prior Authorization and Notification List Humana Humana Healthy Horizons LA prior auth required Oct 14, 2026 Humana Healthy Horizons in Louisiana Prior Authorization and Notification List Humana Humana Healthy Horizons OH prior auth required Oct 14, 2026 Humana Healthy Horizons in Ohio prior authorization and notification List Humana Humana Healthy Horizons OK prior auth required Oct 14, 2026 Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List Humana Humana Healthy Horizons SC prior auth required Oct 14, 2026 Humana Healthy Horizons in South Carolina prior authorization and notification list Humana Humana Healthy Horizons VA prior auth required Oct 14, 2026 Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list Humana Humana MA and D-SNP All prior auth required Jan 1, 2027 Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: Molina Complete Care (Virginia) Medicare-only PA matrix for D-SNP VA prior auth required Jan 1, 2022 Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 Molina Complete Care (Virginia) Medicaid VA prior auth required Apr 1, 2025 Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 Molina Healthcare of Arizona Medicare-only PA matrix for D-SNP AZ prior auth required Jan 1, 2022 Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 Molina Healthcare of California Medicaid CA prior auth required Apr 1, 2026 Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 Molina Healthcare of California Medicare Advantage CA prior auth required Jul 1, 2021 Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 Molina Healthcare of Idaho Medicaid ID prior auth required Jan 1, 2025 Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 Molina Healthcare of Illinois Medicaid IL prior auth required Jan 1, 2022 Molina Healthcare of Illinois Codification Grid Q3 2026 Molina Healthcare of Iowa Medicaid IA prior auth required Jul 1, 2023 IA Prior Authorization Matrix, effective Q3 2023 Molina Healthcare of Michigan Medicaid MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of Michigan Medicare Advantage MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of Mississippi Medicaid MS prior auth required Jan 1, 2025 Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 Molina Healthcare of Nevada Medicaid NV prior auth required Oct 1, 2022 Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 Molina Healthcare of New Mexico Medicaid NM prior auth required Jul 1, 2026 New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 Molina Healthcare of Ohio Medicaid and MyCare Ohio (MMP) Medicaid OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of Ohio Medicare and MyCare Ohio (MMP) Medicare OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of Ohio Exchange OH prior auth required Oct 1, 2023 Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 Molina Healthcare of Texas Exchange TX prior auth required Jul 1, 2021 Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 Molina Healthcare of Utah Medicaid UT prior auth required Jan 1, 2025 Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 Molina Healthcare of Wisconsin Medicare Advantage WI prior auth required Oct 1, 2021 Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 Molina Healthcare, Inc. (national grid) Molina national (MHI) Medicare grid All prior auth required Oct 1, 2021 Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 Passport by Molina Healthcare (Kentucky) Medicaid KY prior auth required Jul 1, 2026 Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Payer coverage policies that name J7402 J7402 appears in 15 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Blue Cross Blue Shield of Massachusetts, Blue Shield of California, BlueCross BlueShield of South Carolina, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence.
Payer Policy Role in policy Reviewed Document Aetna Depemokimab-ulaa (Exdensur) (1098) listed, no stance Aug 10, 2026 payer document Aetna Mometasone Furoate Sinus Implant (Sinuva) (0935) covered if criteria are met Dec 23, 2025 payer document Aetna Omalizumab (0670) listed, no stance Aug 21, 2026 payer document Aetna Tezepelumab-ekko (Tezspire) (1003) listed, no stance Aug 6, 2026 payer document Anthem Drug-Eluting Devices for Maintaining Sinus Ostial Patency (SURG.00132) unproven / investigational Feb 19, 2026 payer document Blue Cross & Blue Shield of Mississippi Steroideluting Sinus Stents And Implants (A.7.01.134) unproven / investigational payer document Blue Cross & Blue Shield of Rhode Island Steroid-Eluting Sinus Stents and Implants sad not covered Apr 15, 2026 payer document Blue Cross Blue Shield of Massachusetts Steroid-Eleuting Sinus Stents (800) covered if criteria are met payer document Blue Shield of California Steroid-Eluting Sinus Stents and Implants (7.01.134) listed, no stance payer document BlueCross BlueShield of South Carolina Steroid-Eluting Sinus Stents and Implants (CAM 701134) listed, no stance Aug 1, 2026 payer document Centene Mometasone Furoate (Sinuva) (CP.PHAR.448) covered if criteria are met Aug 1, 2026 payer document Cigna Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery (0481) unproven / investigational Apr 15, 2026 payer document Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) Drug-Eluting Sinus Implants (SUR706.021) listed, no stance Jan 1, 2026 payer document Premera Blue Cross Steroid-Eluting Sinus Stents and Implants (7.01.134) listed, no stance Oct 14, 2026 payer document Regence Implantable Sinus Devices for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinonasal Polyposis (Surgery 198) listed, no stance Aug 1, 2025 payer document
Recent prior-auth changes Oct 14, 2026: PA removed, Humana Jan 1, 2026: PA added, Molina Healthcare of Michigan Apr 1, 2025: PA removed, UnitedHealthcare Mar 1, 2025: PA added, UnitedHealthcare Jan 1, 2025: PA removed, UnitedHealthcare Jan 1, 2024: PA added, Molina Healthcare of Michigan Jan 1, 2023: PA added, Molina Healthcare of Ohio Feb 23, 2022: PA removed, Blue Shield of California Promise Health Plan Dec 1, 2021: PA added, Blue Shield of California Promise Health Plan Oct 1, 2021: PA added, Molina Healthcare of Wisconsin Medicaid fee-for-service Prior authorization required or conditional in VT, WA.
AZ: $10.78 (asc), effective Oct 1, 2024 IL: $3063.15 (practitioner), effective Apr 1, 2026 IN: $9.75 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2022 KY: $11.35 (asc), effective Jan 1, 2026 MS: $9.08 (comprehensive, facility), effective Oct 1, 2025 NE: $11.34 (injectables), effective Jul 1, 2026 OH: $11.35 (provider_administered_drugs), effective Jan 1, 2023 OK: $11.35 (physician, non-facility), effective Jul 1, 2026 TX: $11.35 (nurse_practitioner_clinical_nurse_specialist, Nurse Practitioner/Clinical Nurse Specialist, non-facility), effective Mar 1, 2025 VA: $11.34 (medical), effective Oct 1, 2023 VT: $8.63 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $11.35 (professional_administered_drugs), effective Jul 1, 2026 WY: $4.91 (outpatient_hospital_apc, Ambulatory Surgical Centers), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.