Eustachian Tube Balloon Dilation

Policy ID: S-262-006

Section: Surgery

Effective Date: July 01, 2019

Revised Date: August 12, 2024

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Balloon dilation is a mechanical method to expand the eustachian tube to relieve the symptoms of Eustachian Tube Dysfunction (ETD) in adults.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Eustachian tube balloon dilation may be considered medically necessary ONCE per ear per lifetime or bilaterally ONCE per lifetime, in individuals (18 years and older) when ALL of the following criteria have been met:

Individuals with symptoms of obstructive ETD (aural fullness, aural pressure, otalgia, and/or hearing loss) for six (6) months or longer in one (1) or both ears that significantly affects quality of life or functional health status:
- Aural fullness and pressure must be present; and
The individual has undergone a tympanometry examination with ONE the following findings:
- Abnormal tympanogram (Type B or C); or
- Abnormal tympanic membrane (retracted membrane, effusion, perforation, or any other abnormality identified on exam); and
The individual has failed to respond to appropriate medical management including:
- Four-six (4 to 6) weeks of a nasal steroid spray; or
- One (1) week of oral steroids, if indicated; and
The individual's ETD has been shown to be reversible:
- Reversibility of ETD can be demonstrated by several means, including any of the following:
  - The individual states that they are able to relieve the pressure by performing a Valsalva maneuver to 'pop' their ears; or
  - Performing a Valsalva maneuver produces temporary improvement of the individual's tympanogram to Type A tympanogram; or
  - Performing a Valsalva maneuver causes the member's middle ear to aerate, which is indicated by the provider visualizing lateral movement of the tympanic membrane on otoscopy.

Quantity level limits (QLLs) that exceed the frequency guidelines listed on the policy are considered not medically necessary.

Eustachian tube balloon dilation not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness if this service cannot be established by the available published peer-review literature.

Procedure Codes

69705

69706

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: 69705 and 69706

H65.21

H65.22

H65.23

H66.001

H66.002

H66.003

H66.004

H66.005

H66.006

H66.011

H66.012

H67.1

H67.2

H67.3

H68.001

H68.002

H68.003

H68.021

H68.022

H68.023

H69.81

H69.82

H69.83

H69.91

H69.92

H69.93

H71.01

H71.02

H71.03

H71.11

H71.12

H71.13

H71.21

H71.22

H71.23

H71.31

H71.32

H71.33

H71.91

H71.92

H71.93

H72.01

H72.02

H72.03

H72.11

H72.12

H72.13

H72.2X1

H72.2X2

H72.2X3

H72.811

H72.812

H72.813

H72.821

H72.822

H72.823

H72.91

H72.92

H72.93

H90.0

H90.11

H90.12

H90.3

H90.41

H90.42

H90.6

H90.71

H90.72

H90.A11

H90.A12

H90.A21

H90.A22

H90.A31

H90.A32

H91.01

H91.02

H91.03

H91.11

H91.12

H91.13

H91.21

H91.22

H91.23

H91.8X1

H91.8X2

H91.8X3

H91.91

H91.92

H91.93

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020

Revised clinical criteria; and
Updated diagnosis codes

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed procedure code 69799; and
Added procedure codes 69705; 69706

Internal Medical Policy Committee 1-20-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2022 Revision of criteria, language and coding update:

Removed HCPCS (C code) C9745
Added the following covered Diagnosis codes for Procedure codes 69705 and 69706:

- H67.1; H67.2; H67.3; H71.01; H71.02; H71.03; H71.11; H71.12; H71.13; H71.21; H71.22; H71.23; H71.31; H71.32;H71.33; H71.91; H71.92; H71.93; H72.01; H72.02; H72.03; H72.11; H72.12; H72.13; H72.2X1; H72.2X2; H72.2X3; H72.811;H72.812; H72.813; H72.821; H72.822; H72.823; H72.91; H72.92; H72.93; H90.0; H90.11; H90.12; H90.3; H90.41; H90.42;H90.6; H90.71; H90.72; H90.A11; H90.A12; H90.A21; H90.A22; H90.A31; H90.A32; H91.01; H91.02; H91.03; H91.11; H91.12; H91.13; H91.21; H91.22; H91.23; H91.8X1; H91.8X2; H91.8X3; H91.91; H91.92; H91.93

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review-no changes in criteria

Added Policy Application

Internal Medical Policy Committee 9-17-2024 Coding update - Effective November 04, 2024

Removed diagnosis codes H68.009; H68.029; H69.80; and H69.90.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-262-005