Eustachian Tube Balloon Dilation

Section: Surgery
Effective Date: July 01, 2019
Revised Date: May 30, 2019
Last Reviewed: May 15, 2019

Description

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

Criteria

Eustachian tube balloon dilation may be considered medically necessary in adult individuals (18 years and older) with ALL the following criteria:

  • Diagnosis of chronic ETD; and
  • Tympanogram type B or C; and
  • Absence of a co-morbid condition that would be contraindicated for balloon dilation including but not limited to:
    • Carotid abnormalities in the skull base; or
    • Patulous eustachian tube

Eustachian tube balloon dilation is considered experimental/investigational for all other indications and therefore non-covered because the safety and/or effectiveness have not been established.

Procedure Code

69799

Outpatient HCPCS (C Codes)

C9745

Diagnosis Codes

H68.0H69.8H69.9H65.21H65.22H65.23H66.001
H66.002H66.003H66.004H66.005H66.006H66.011H66.012
H66.013H66.014H66.015H66.016T70.0XXAT70.0XXDT70.0XXS

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