Author: CSRA
Effective with date of service March 8, 2018, the North Carolina Medicaid and N.C. Health Choice (NCHC) programs cover mometasone furoate sinus implant (Sinuva) for use in the Physician's Drug Program (PDP) when billed with HCPCS code J3490 - Unclassified drugs. One Sinuva Sinus Implant system contains 1350 mcg of mometasone furoate and a sterile delivery system.
Sinuva is indicated for the treatment of nasal polyps in patients 18 years of age and older who have had ethmoid sinus surgery. One Sinuva Sinus Implant contains 1350 mcg of mometasone furoate, which is loaded into a delivery system and placed in the ethmoid sinus under endoscopic visualization and left in the sinus to gradually release the corticosteroid over 90 days. It may be removed at day 90 or earlier at the physician's discretion. Repeat administration has not been studied.
See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis codes required for billing are J33.0 - Polyp of nasal cavity; J33.1 - Polypoid sinus degeneration; J33.8 - Other polyp of sinus and J33.9 - Nasal polyp, unspecified.
- Providers must bill with HCPCS code J3490 - Unclassified drugs.
- One Medicaid and NCHC unit of coverage is 1 implant.
- The maximum reimbursement rate per unit is $1,377.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs is 10599-0003-01.
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
- For additional information regarding NDC claim requirements related to the PDP, refer to the PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on Medicaid’s website.
- Providers shall bill their usual and customary charge for non-340-B drugs.
- PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340-B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340-B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340-B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PDP is available on Medicaid’s PDP web page.
CSRA, 1-800-688-6696