Medical Policy



Subject: Devices for Maintaining Sinus Ostial Patency Following Sinus Surgery
Document #: SURG.00132 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description/Scope

This document addresses devices placed within the sinuses for the purpose of maintaining sinus ostial patency following functional endoscopic sinus surgery (FESS) (for example, Propel® Mometasone Furoate Implant [Intersect ENT, Inc., Menlo Park, CA]).   

Position Statement

Investigational and Not Medically Necessary:

The use of devices for maintaining sinus ostial patency following sinus surgery is considered investigational and not medically necessary for all indications.

Rationale 

Sinus surgery is commonly used for the treatment of individuals with chronic rhinosinusitis, infection and polyposis.  FESS is intended to open closed sinus ostia to allow proper drainage and air flow and prevent recurrent sinus infections.  Inflammation, polyp recurrence, stenosis of the surgically enlarged sinus ostia, adhesions and middle turbinate lateralization (adhesion of the middle turbinate to the lateral nasal wall) represent suboptimal outcomes following sinus surgery and lead to increased rates of revision.  Middle turbinate lateralization may cause obstruction of the middle meatus and result in recurrent infection of the maxillary, ethmoid, or frontal sinuses (Otto, 2010).  Several devices have been proposed that are designed to help maintain sinus ostial patency by reducing scarring and synechiae formation following FESS.  These include stents, packing, sponges, and gels. 

Propel Mometasone Furoate Implant

The Propel sinus implant and the Propel Mini Steroid-Releasing Implant, are the only devices of their kind with FDA approval.  These devices are bioabsorbable drug-eluting stents that may be implanted into the sinus ostia following FESS and are designed to release the corticosteroid mometasone furoate over a period of several weeks as the stent itself is slowly resorbed.  It is proposed that this type of stent has the potential to improve surgical results by stabilizing the middle turbinate, preventing obstruction by adhesions and reducing edema.  The Propel devices are designed to deliver corticosteroids to the surgical cavity with minimal potential for drug-related complications known to occur with systemic steroids and lessen the need for revision surgery to lyse adhesions.  At this time, there are several peer-reviewed published clinical trials addressing the use of this device.  The first three papers describe the three trials presented to the FDA during the pre-market approval (PMA) process.  These studies are known as the ADVANCE, CONSENSUS II and the ADVANCE II trials.  The latter two are randomized intra-patient controlled trials, while the ADVANCE trial was a case series. 

The CONSENSUS II study, described in the article by Murr and colleagues (2011), was the first clinical trial to evaluate the safety and effectiveness of the Propel device in humans.  CONSENSUS II was a small, randomized, double-blind, four-center pilot study.  The objective of the study was to assess the safety, effectiveness, and performance of the Propel device when used following FESS in subjects with chronic ethmoid rhinosinusitis.  Subjects studied were adults with a diagnosis of chronic rhinosinusitis with or without nasal polyps scheduled to undergo primary (bilateral ethmoidectomy with middle meatal antrostomy) or revision FESS.  However, concurrent septoplasty and surgical treatment of other paranasal sinuses was also permitted. 

In the CONSENSUS II feasibility trial, a total of 43 subjects received a 23 mm Propel sinus implant while 7 received a shorter version.  The study used an intra-patient control design to compare the safety and efficacy of the drug-eluting Propel sinus implant to a non-drug-eluting control version of the implant in the contralateral ethmoid sinus ostium.  As a result, both ethmoid sinuses received the Propel stent's scaffolding function.  Implant delivery was judged successful in 100% of the subjects and there was a statistically significant difference in reduction of ethmoid sinus inflammation postoperatively (endoscopic visual analog scale) at days 21-45 (p≤0.003).  Also reported were statistically significant reductions in the frequency of polyp formation and adhesions in the treatment arm.  Although a reduced frequency of middle turbinate lateralization was seen on the drug-eluting stent side, the difference was not statistically significant.  No device-related adverse events were reported, and eluted steroid was not detectable systemically and no evidence of adrenal suppression was found.

The ADVANCE study, described in the article by Forwith et al. (2011), was an open-label, prospective case series involving 50 subjects with either single or bilateral ethmoid sinus disease requiring FESS at seven study centers.  The study allowed bilateral or unilateral steroid-eluting implant placement.  Oral and topical steroids were withheld for 60 days postoperatively.  Follow-up assessments occurred prior to hospital discharge or clinic release and at days 7, 14, 21, 30 and 60 post procedure.  An additional final visit occurred at 6 months, but only a subject questionnaire was collected.  Forty-nine of the 50 subjects completed the study through 60 days, representing a follow-up rate of 98%, and 45 subjects (90%) completed follow-up through 6 months.  Endoscopic follow-up was performed to 60 days post-operatively and self-reported outcomes using three scales (Sinonasal Outcomes Test 22, Rhinosinusitis Disability Index, and Total Nasal Symptom Scoring) were followed to 6 months.  Implants were successfully placed in all 90 sinuses.  At 1 month, polypoid edema was 10.0%, significant adhesions 1.1%, and middle turbinate lateralization 4.4%.  These results compared favorably with historic controls using other methods: 19% incidence of post-operative lysis of adhesions using absorbable hyaluronic acid packing (Miller, 2003) and 6% incidence of adhesions using nonabsorbable silastic sheets following FESS (Lee, 2007).  Favorable mean changes from baseline to day 60 and 6 months in the three self-reported surveys were statistically significant.

The ADVANCE II  study, described by Marple and colleagues (2012), was a prospective, randomized, double-blind, intra-patient controlled, multi-center study that enrolled 105 subjects at 11 US sites evaluating the safety and effectiveness of the Propel device following bilateral ethmoidectomy for chronic rhinosinusitis.  Subjects were randomized to receive the Propel device in one ethmoid sinus and a non-drug-eluting stent device identical in structure and appearance to the Propel device in the contralateral ethmoid sinus.  This methodology assisted in the blind nature of the study.  The primary effectiveness endpoint was reduction in post-operative interventions.  The primary safety endpoint was ocular safety defined as absence of clinically significant sustained elevation (≤ 10 mm Hg) in intraocular pressure through day 90.  The primary efficacy endpoint was the reduction in need for post-operative interventions at day 30, as determined from video-endoscopies reviewed by a panel of three independently blinded sinus surgeons.  Implants were successfully deployed in all 210 ethmoid sinuses.

Follow-up assessments occurred prior to hospital discharge or clinic release and at post-operative days 14, 30, 60 and 90 post procedure.  A total of 102 subjects completed the follow-up visits through 90 days, representing a follow-up rate of 97.1%.  Also, 103 of the 105 subjects completed the ocular follow-up visits through 90 days (98.0%).  No subject required termination from the study due to an adverse event.  The primary safety endpoint was met.  There were no clinically significant elevations in intraocular pressure and no clinically significant changes in lens opacities through day 90.  Recurrent sinusitis was the most frequently reported adverse event type, reported in 34 of the 105 subjects (32.4%).  Sinusitis was the only event type localized by sinus side; this was possible in 14 of the events, with 6 occurring on treatment sides and 8 occurring on the control sides.  Two of the adverse events (sinusitis) were determined to be related to the study device, and both resolved without sequelae.  There were no serious adverse events reported in the study.  Compared with control sinuses with non-drug-eluting implants, the drug-eluting implant provided a 29% (23 vs. 33) relative reduction (p=0.028) in post-operative interventions (composite of either surgical adhesion lysis and/or oral steroids).  The reduction in post-operative interventions was driven largely by the reduction in lysis of adhesions.  The rate of adhesion lysis was reduced by 52% (p=0.005), and while the need for oral steroids was reduced by 29% this difference did not reach statistical significance.  The relative reduction in frank polyposis was 44.9% (16 vs. 29; p=0.002).

The results of these controlled studies are promising; however, they were limited to small, heterogeneous populations with short follow-up.  In addition, the studies were conducted in a setting where both sinuses had implants, one with steroid and the other without.  The comparative trials described above did not compare the post-operative outcomes using this device with outcomes following standard FESS without an ostial implant but with topical steroid sprays, saline irrigation, debridement, and conventional postoperative packing.   

The RESOLVE study was a patient-blinded, randomized controlled trial (RCT) involving 100 subjects with chronic rhinosinusitis who were scheduled to undergo revision FESS following prior ethmoidectomy due to recurrent obstruction related to polyposis (Han, 2014).  Subjects were assigned to undergo treatment with the Propel device (n=53) or sham procedure (n=47) and followed for 90 days.  In the Propel group, the implant was planned to be removed at 60 days to avoid unblinding by inadvertent dislodgement of the device due to their gradual softening and resorption.  The mean percentage of implants remaining in place at 30, 45 and 60 days was 92.5%, 86.5% and 56.7%, respectively.  No serious adverse events were reported.  At 90 days, compared to the control group, the Propel group had significantly better bilateral polyp grade (p=0.016) and less ethmoid obstruction (p=0.0001).  The authors reported a significant improvement in the patient-reported symptom outcomes, with a two-fold reduction seen in the Propel group vs. controls (p=0.025).  However, no validated tool was used to make this assessment so these results are of uncertain value.  During the post-operative period, fewer Propel group subjects required oral steroids for ethmoid obstruction (11% vs. 26%; no p-value provided), and fewer Propel group subjects met the criteria for FESS (47% vs. 77%; no p-value provided).  One control subject and 2 Propel subjects underwent FESS before the end of the trial period.  This study, while only single-blinded and limited in follow-up time, was fairly well conducted and the reported results are promising.  However, further research in warranted in larger populations.

Forwith and others (2016) published the 6-month results of the RESOLVE study described above.  At 6 months, it was reported that Propel group subjects experienced significant improvement in Nasal Obstruction Symptom Evaluation (NOSE) score (p=0.021) and greater than 2-fold improvement in mean nasal obstruction/congestion score compared to controls (-0.06 ± 1.4 vs -0.44 ± 1.4; p=0.124).  Endoscopically, Propel group subjects experienced significant reduction in ethmoid sinus obstruction (p<0.001) and bilateral polyp grade (p=0.018) compared to controls.  Panel review confirmed a significant reduction in ethmoid sinus obstruction (p=0.010) and 2-fold improvement in bilateral polyp grade (p=0.099), which reached statistical significance (p=0.049), in a subset of 67 subjects with baseline polyp burden greater than or equal to 2 bilaterally.  The authors reported that at 6 months, control group subjects were 3.6 times more likely to remain candidates for FESS than the Propel groups subjects.  These results are promising, but the small sample size limits their generalizability .

Finally, several smaller case series studies have also been published addressing this device (Lavigne, 2014; Matheny, 2014; Ow, 2014).  These studies are quite small, with study populations between 2 and 20, and their methodology weak.  Data from such studies are not particularly useful when viewed in the light of the previously available evidence from the ADVANCE, CONSENSUS II and the ADVANCE II trials.

Relieva Stratus™ MicroFlow Spacer (Frontal and Ethmoid)

Another device proposed for maintaining the patency of sinus ostia for up to 14 days postoperatively following sinus surgery is the Relieva Stratus MicroFlow Spacer (Frontal) or the Relieva Stratus MicroFlow Spacer (Ethmoid) (Acclarent™, Menlo Park, CA).  These devices were cleared in 2009 by the FDA for use with saline solution to maintain patent ethmoid and frontal ostia following sinus surgery.  In 2015 they were removed from the market in the U.S. and are not currently available for sale. 

When used as indicated, the Stratus devices are placed endoscopically with fluoroscopy and manually removed during an office follow-up visit.  These devices are catheter-based, self-retaining implantable devices with a porous reservoir for moistening the sinuses following surgery.  At this time, there is insufficient evidence from controlled clinical trials to establish the safety and efficacy of these devices.

Recommendations

Both the American Rhinologic Society (ARS) and the American Academy of Otolaryngology‑Head and Neck Surgery (AAO-HNS) have published position statements regarding the use of "biomaterials."  The ARS does not supply any citations to support their statement, which does not allow sufficient evaluation of the evidentiary basis of their position.  The AAO-HNS statement does include citations, but they do not include any studies not previously discussed above.  As stated above, these studies do not sufficiently demonstrate the safety and efficacy of these devices.

Background/Overview

The Propel sinus implant is a bioabsorbable drug-eluting sinus stent designed to maintain patency of the ethmoid sinus ostia following FESS for chronic rhinosinusitis.  It is manufactured from a synthetic bioabsorbable copolymer, poly (L-lactide-co-glycolide, PLG) and impregnated with mometasone furoate, a synthetic corticosteroid with anti-inflammatory activity.  The device is designed to be bioabsorbed over a period of 30-45 days.  During that period, the Propel device is proposed to maintain sinus patency by reducing inflammation, significant polyp formation, adhesions, and edema in individuals 18 years of age and older. 

The device is implanted into the ethmoid sinus ostia by a physician under endoscopic visualization.  The physician uses a proprietary endoscopic delivery system to position and insert the Propel device in the desired location.  Upon insertion, the implant expands radially to conform to the surgically enlarged sinus ostium following FESS.  Once the stent is in place, the mometasone furoate is released to the local area surrounding the stent.  The Propel device was approved by the FDA as a combination product on August 11, 2011.

The Stratus Microflow Spacer is a device designed to provide slow release of fluid into the sinuses over a period of 2 weeks with the intention of maintaining sinus ostial patency.  This device may be used in either the frontal or ethmoid sinuses.  However, the manner in which it is deployed for these locations is significantly different. 

For the frontal sinus, the device is inserted into the sinus ostia and then filled with saline.  The center of the device is a fluid reservoir and the outer section is an angioplasty-like balloon with laser drilled micropores that allow the fluid to weep out over a period of 2 weeks.  The device does not completely fill the ostial lumen, which allows sinus drainage around the device.  The Stratus Microflow Spacer is held in place with plastic "retention wings" that deploy once the device in place.  For the ethmoid sinus, the device is inserted through the wall of the ethmoid sinus, not into the ostia.  This involves the use of a special device to pierce the sinus wall to allow implantation of the spacer.  When used in either the frontal sinus or the ethmoid sinus, the device is intended to remain in place for 2 weeks and then is removed in the doctor's office.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary. 

CPT  
31299 Unlisted procedure, accessory sinuses [when specified as insertion of a sinus stent or spacer]
0406T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant;
0407T Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement
   
HCPCS  
L8699 Prosthetic implant, not otherwise specified [when specified as sinus stent or spacer implant]
S1090 Mometasone furoate sinus implant, 370 micrograms [Propel sinus implant]
   
ICD-10 Diagnosis  
  All diagnoses

When services are also Investigational and Not Medically Necessary:
Note:  The correct procedure code for the Propel sinus implant is S1090, which is specific to that device. If the following code is used, the service will be considered investigational and not medically necessary for the listed diagnosis codes. 

HCPCS  
C1874 Stent, coated/covered, with delivery system
   
ICD-10 Diagnosis  
J01.00-J01.91 Acute sinusitis
J32.0-J32.9 Chronic sinusitis
J33.1 Polypoid sinus degeneration
J33.8 Other polyp of sinus
J34.1 Cyst and mucocele of nose and nasal sinus
J34.89-J34.9 Other specified/unspecified disorders of nose and nasal sinuses
   
References

Peer Reviewed Publications:

  1. Catalano PJ, Thong M, Weiss R, Rimash T. The MicroFlow Spacer: a drug-eluting stent for the ethmoid sinus. Indian J Otolaryngol Head Neck Surg. 2011; 63(3):279-284.
  2. Forwith KD, Chandra RK, Yun PT, et al. ADVANCE: a multisite trial of bioabsorbable steroid-eluting sinus implants. Laryngoscope. 2011; 121(11):2473-2480.
  3. Forwith KD, Han JK, Stolovitzky JP, et al. RESOLVE: bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis after sinus surgery: 6-month outcomes from a randomized, controlled, blinded study. Int Forum Allergy Rhinol. 2016; 6(6):573-581.
  4. Han JK, Forwith KD, Smith TL, et al. RESOLVE: a randomized, controlled, blinded study of bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis. Int Forum Allergy Rhinol. 2014; 4(11):861-870.
  5. Han JK, Marple BF, Smith TL, et al. Effect of steroid-releasing sinus implants on postoperative medical and surgical interventions: an efficacy meta-analysis. Int Forum Allergy Rhinol. 2012; 2(4):271-279.
  6. Marple BF, Smith TL, Han JK, et al. Advance II: a prospective, randomized study assessing safety and efficacy of bioabsorbable steroid-releasing sinus implants. Otolaryngol Head Neck Surg. 2012; 146(6):1004-1011.
  7. Murr AH, Smith TL, Hwang PH, et al. Safety and efficacy of a novel bioabsorbable, steroid-eluting sinus stent.  Int Forum Allergy Rhinol. 2011; 1(1):23-32.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Otolaryngology-Head and Neck Surgery. Position statement: The use of Biomaterials in Sinonasal Procedures. 9/26/2015. Available at: http://www.entnet.org/content/position-statement-use-biomaterials-sinonasal-procedures. Accessed on May 30, 2017.
  2. American Rhinologic Society. Position statement: Biomaterials (January 24, 2014). Available at: https://www.american-rhinologic.org/position_biomaterials . Accessed on May 30, 2017.
Index

PROPEL® mini sinus implant
Propel sinus implant
Relieva Stratus MicroFlow Spacer
Sinuva

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Index sections.
Reviewed 08/04/2016 MPTAC review. Updated Rationale and Reference sections.
  01/01/2016 Updated Coding section with 01/01/2016 CPT changes; removed ICD-9 codes.
Reviewed 08/06/2015 MPTAC review. Updated Rationale, Coding and Reference sections.
Reviewed 08/14/2014 MPTAC review. Updated Reference section.
Reviewed 08/08/2013 MPTAC review. Updated Reference section.
New 08/09/2012 MPTAC review. Initial document development.