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
