Transtympanic Micropressure Applications as a Treatment of Meniere’s Disease (ARCHIVED)

Policy ID: E-41-014

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: August 02, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective September 2, 2024. Click the Archive tab above for more information.

Policy ID: E-41-013

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Last Reviewed: July 26, 2023

Archived Date: September 02, 2024

Applies To: Commercial and Medicaid Expansion

Description

Transtympanic micropressure pulses (Meniett Device) are transmitted to the middle ear to cause displacement of the perilymphatic fluid, thus relieving the symptoms of Meniere’s disease.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Transtympanic micropressure applications (e.g. Meniett device) as a treatment of Meniere’s diseaseare considered not medically necessary.

Procedure Codes

A4638

E2120

Diagnosis Codes

H81.01

H81.02

H81.03

H81.09

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 7-22-2021 Annual Review

Internal Medical Policy Committee 7-21-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-16-2024 Archived - Effective September 02, 2024

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.

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