Aetna Myringotomy/Tympanostomy Coverage Update

inv-01: Medically necessary indications

Tympanostomy tube insertion is considered medically necessary when ANY of the following indications are present:

Permitted indications: 1) Autophony due to patulous eustachian tube; 2) Barotitis media control; 3) Children with cleft palate and history of otitis media with effusion and persistent hearing loss; 4) Cholesteatoma; 5) Chronic retraction of the tympanic membrane or pars flaccida; 6) Complications of otitis media (e.g., meningitis, facial nerve paralysis, coalescent mastoiditis, brain abscess); 7) Otitis media with effusion (OME) after 3 months or longer with bilateral hearing impairment (defined as 20 dB hearing threshold level or worse in both ears); 8) Recurrent acute otitis media (>3 episodes in 6 months or >4 episodes in 12 months); 9) Severe otalgia in acute otitis media (indication for myringotomy); 10) To obtain middle ear culture (diagnostic tympanocentesis/myringotomy) prior to initiating or changing antimicrobial therapy when clinically necessary.

Any single listed indication qualifies; derived from policy Section I.

inv-02: BDET criteria (adults)

Balloon dilation of the Eustachian tube (BDET) is medically necessary in adults when ALL of the following criteria are met:

BDET adult criteria: 1) Diagnosis of chronic/obstructive Eustachian tube dysfunction with symptoms present for 3 months or longer that significantly affect quality of life or functional status; AND 2) Objective abnormality on testing (tympanogram type B or C) OR documented prior symptomatic improvement while tympanostomy tubes were patent; AND 3) Absence of contraindicating co-morbid conditions (e.g., carotid/skull base abnormalities, nasopharyngeal or skull base neoplasm, patulous Eustachian tube, untreated allergic rhinitis/rhinosinusitis or laryngopharyngeal reflux).symptoms >= 3 months

Preserves nested logic: tympanogram OR prior tube benefit as part of required criteria.

inv-03: AAO-HNS clinical practice guideline recommendations

Guideline-based candidacy statements and follow-up recommendations from AAO-HNS:

Candidacy and follow-up guidance (AAO-HNS): - Do not perform tympanostomy tube insertion for a single episode of OME lasting less than 3 months; - Obtain age‑appropriate audiometry if OME persists ≥3 months or prior to surgery when a child becomes a candidate for tubes; - Offer bilateral tubes for children with bilateral OME ≥3 months with documented hearing difficulties; - Re-evaluate children with chronic OME who did not receive tubes at 3- to 6-month intervals until effusion resolves, significant hearing loss is detected, or structural abnormalities are suspected; - Do not place long‑term tubes as initial surgery unless a specific anticipated need exists; - Do not routinely prescribe post‑operative antibiotic ear drops; - Do not routinely recommend prophylactic water precautions for children with tubes.

Direct recommendations summarized from AAO‑HNS guideline statements.

inv-04: Non-surgical autoinflation

Evidence and suggested sequencing for non-surgical options:

Autoinflation/EarPopper evidence: Autoinflation devices (e.g., EarPopper) have favorable short‑term evidence for OME; randomized trials in children with persistent OME (~≥3 months) showed improvement in hearing and reduced ventilation tube insertion rates compared with control, though studies are small and long‑term effects are uncertain.

Consider a documented trial of autoinflation prior to surgical intervention when clinically appropriate.

inv-05: Coverage criteria for BET

BET may be considered when ALL of the following are met

Primary criteria for BET: 1) Symptomatic Eustachian tube dysfunction documented by a validated symptom score (e.g., ETDQ‑7) or consistent symptoms (ear pressure/fullness, reduced ability to Valsalva); 2) Objective abnormality on testing (e.g., abnormal tympanogram, inability to perform Valsalva, abnormal otoscopy or ET score); 3) Symptoms are persistent and refractory to well‑conducted medical and pressure therapies; 4) Procedure is performed by trained clinicians with appropriate clinical governance, procedural documentation, and follow‑up arrangements.

Criteria reflect RCTs and systematic reviews showing BET studied in medically refractory ETD with objective baseline abnormalities.

inv-06: BDET — candidate coverage criteria

Covered when ALL of the following are met

BDET candidate criteria: 1) Adult patient (age ≥18 years) with symptoms of obstructive Eustachian tube dysfunction for ≥3 months; 2) Symptoms significantly affect quality of life or functional status; 3) Documented failure of well‑conducted medical management (including appropriate medical and pressure therapies); 4) Procedure performed with standard arrangements for clinical governance, informed consent, and audit.all conditions required

Based on AAO‑HNS consensus and NICE guidance that BDET is indicated for chronic ETD refractory to medical treatment.

inv-07: Candidate selection

Evidence summary and typical candidate criteria (as represented in the literature):

Typical inclusion features reported in studies: Patients selected in observational studies and trials commonly had symptomatic ETD with objective abnormal findings (abnormal tympanogram, impaired ability to Valsalva, elevated ETDQ‑7) and symptoms refractory to medical therapy; pediatric series frequently included patients with prior tympanostomy tubes or failed standard therapies.

Derived from multiple systematic reviews, meta‑analyses, RCTs, and registry cohorts.

inv-08: Outcomes and safety

Outcomes and safety considerations reported:

Reported benefits: Improvement in ETDQ‑7 scores, tympanogram normalization, increased ability to perform Valsalva, and reductions in air‑bone gap have been reported in adult RCTs, registries, and systematic reviews with benefits durable up to months/years in some studies.

Effect sizes and durability vary; strongest adult RCT evidence shows sustained tympanogram normalization.

Reported harms: Adverse events are generally low; pooled pediatric AE estimates ~5.1% (mostly self‑limited epistaxis) and individual series report minor events (epistaxis, transient vertigo); serious complications are uncommon but longer‑term pediatric RCT data are limited.

Evidence quality varies; report pooled AE rates and limitations.

inv-09: In-office tympanostomy tube placement

Coverage considerations for in-office tympanostomy tube placement using iontophoresis/TDS:

In‑office tube placement (Tula/TDS) suggested conditions: 1) Patient selection documented with shared decision‑making and suitability for awake in‑office procedure; 2) Patient is ≥6 months of age and has no contraindication (e.g., perforated tympanic membrane, allergy to local anesthetic); 3) Clinician documents behavioral support/sedation plan and successful iontophoretic anesthesia prior to tube delivery; 4) Procedure outcomes and follow‑up (tube retention, otorrhea, perforation) are documented.age >= 6 months

Evidence shows technical success and acceptable tolerability in selected cohorts; long‑term retention and complication profiles still under follow‑up.

inv-10: Eustachian tube dilation and soft-tissue interventions

Coverage considerations for Eustachian tube procedures:

Eustachian tube interventions overview: Evidence for Eustachian tube interventions varies: transnasal BDET has randomized and registry data supporting safety and efficacy in adults; trans‑tympanic balloon dilatation has limited and conflicting case‑series and cadaver data with unresolved safety questions; soft‑tissue fillers for patulous ET are supported mainly by small case series and lack high‑quality evidence.

Techniques without adequate controlled evidence should be considered investigational pending further data.

inv-11: Evidence summaries and coverage-relevant findings

Evidence-based considerations and observed outcomes

Iontophoretic lidocaine/epinephrine safety: Randomized pharmacokinetic safety data in healthy adults demonstrated low systemic lidocaine and epinephrine levels (lidocaine Cmax ≈2.24 ng/mL), approximately 2,000‑fold below minor toxicity thresholds, with no device-, procedure-, or drug-related adverse events reported.lidocaine Cmax ~2.24 ng/mL

Safety data from healthy adult volunteers; effectiveness in children with otitis media not assessed in that study.

Behavioral and tolerability findings in pediatrics: Behavioral programs plus iontophoresis and automated tube delivery were associated with low procedural distress scores (mean FPS‑R ~3.30 for ages 5–12; mean FLACC ~4.0 for ages 6 months–4 years) and high parental satisfaction in cohort studies.FPS‑R 3.30; FLACC 4.0

Studies were single‑arm and have limited generalizability to all pediatric populations.

In‑office tube outcomes and complications:

The policy lists procedures and indications that are considered experimental/investigational and excluded. This includes myringotomy/tympanostomy tube insertion for indications not enumerated in the policy’s medically necessary section (for example, prophylactic tube placement in populations without other qualifying indications), use of soft‑tissue fillers for patulous Eustachian tube, phosphorylcholine‑ or vancomycin‑coated tympanostomy tubes, and the EarPopper device for OME/ETD. The policy also lists procedures related to Eustachian tube interventions that remain investigational: repeat or salvage BDET (after initially successful or unsuccessful BDET, or performed with concurrent tympanoplasty), trans‑tympanic balloon dilatation of the Eustachian tube, and the Tubes Under Local Anesthesia (Tula) System for otitis media as experimental. These items are excluded because effectiveness has not been established in the available literature and trial designs are limited.

Per guideline-based recommendations adopted in the policy, tympanostomy tube insertion is not indicated for children with a single episode of otitis media with effusion lasting less than 3 months. Clinicians should observe a period of watchful waiting for approximately 3 months in most children with OME and obtain age‑appropriate audiometry if effusion persists or the child becomes a surgical candidate.

Evidence in special populations raises caution: in a retrospective series of children with Cornelia de Lange syndrome, tympanostomy tube insertion (VTI) rarely improved conductive hearing loss because middle‑ear soft tissue lesions — rather than fluid effusion — were frequently present. The report concluded that VTI was ineffective for hearing improvement in that cohort, indicating limited expected benefit for similar patients.

Balloon Eustachian tuboplasty (BET) is described as promising but the evidence base is limited. Systematic reviews and case‑series syntheses found symptomatic and tympanometric improvements in many reports but emphasized that most studies are poor quality, uncontrolled, and biased. Consequently, BET remains insufficiently proven for indications without objective documentation of Eustachian tube dysfunction or for patient populations not represented in the studies; randomized trials and consistent objective selection criteria are needed before broader confidence in effectiveness.

Use of balloon dilation of the Eustachian tube (BDET) is supported only when patients meet the policy’s chronic ETD criteria. The policy explicitly states that BDET is not supported for patients who do not have chronic obstructive ETD refractory to appropriate medical and pressure therapies. Performing BDET as routine first‑line therapy in patients who have not failed conservative management is not aligned with the evidence or policy criteria.

Current pediatric evidence does not support widespread first‑line use of BDET in children. Many pediatric series used BDET as a second‑line option after failed standard treatments (adenoidectomy, ventilation tubes, medical therapy), and systematic reviews conclude quality of evidence is inadequate to recommend BET as a first‑line approach in children. The policy therefore recommends reserving BDET for children who have failed standard therapies and when objective findings support the diagnosis.

Limitations and contraindications for the Tula (in‑office) system are described: the device is FDA‑cleared for use in patients aged ≥6 months, and the system should not be used in patients younger than 6 months, in patients with a perforated tympanic membrane, or in patients with allergies to certain local anesthetics. Published reports also note trial inclusion criteria that restrict use to children with anatomy and behavior compatible with safe office procedures.

The policy highlights evidence gaps concerning rapid‑insertion or modified tympanostomy tubes: relatively little is known about their long‑term efficacy, duration of function, or complication profiles. Available data are frequently industry‑funded, involve modest sample sizes, and often lack control groups — factors that limit generalizability and warrant caution when counseling families about expected outcomes.

This Clinical Policy Bulletin provides a summary of Aetna’s coverage approach and is intended to assist in administering benefits; it does not constitute a contract, provide a complete description of member benefits, or replace plan documents. The bulletin may be updated and is subject to change.

The policy specifies interventions that are considered not medically necessary. Notably, tympanostomy tube insertion is not medically necessary for a child with a single episode of OME lasting less than 3 months. Other listed non‑indications include children with recurrent AOM who do not have middle‑ear effusion at assessment. Clinicians should follow guideline‑based reassessment and documentation before proceeding with tube placement.

Routine prescription of post‑operative topical antibiotic ear drops after tympanostomy tube placement is not recommended by guideline guidance cited in the policy. Post‑operative antibiotic ear drops are therefore not routinely necessary and are not supported as standard practice.

BET (including BDET) performed for isolated or transient Eustachian tube complaints without objective documentation of dysfunction or without prior failure of medical/pressure therapies is not supported by high‑quality evidence. The policy treats BET in these circumstances as investigational or not medically necessary pending objective testing and documentation of refractory ETD.

BDET as a first‑line intervention for patients who have not first failed standard medical or surgical therapies is not supported by the evidence reviewed. Most studies enrolled patients after prior conservative or surgical treatments had failed; therefore, BDET is described in the policy as appropriate mainly as a second‑line option when selection criteria are met and prior therapies have been attempted.

Soft‑tissue fillers for patulous Eustachian tube and trans‑tympanic balloon dilatation have been reported primarily in small case series, pilot studies, and cadaver work. The policy notes that these techniques are supported mainly by limited low‑quality evidence and thus should be considered investigational until more robust controlled data are available.

Economic analyses cited in the policy indicate that tympanostomy tubes may not be cost‑effective compared with medical management in some pediatric scenarios. A Markov decision model found tympanostomy tube placement produced small quality‑of‑life gains at substantially higher cost, corresponding to approximately $520,855 per QALY compared with medical management; medical therapy was favored in the majority of probabilistic sensitivity analyses.

Provider Actions — Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for some procedures and CPT codes listed in this policy. Providers should check payer-specific rules and obtain authorization when required before scheduling to avoid claim denials or delays.

Prior authorization likely required for covered CPTs when selection criteria apply
Confirm authorization requirements for BDET (69705/69706) and in‑office tube systems (0583T) with Aetna

Documentation Required

Post-Operative Follow-Up and Documentation

Obtain and document pre- and post-operative assessments. Initial post-operative review is recommended within 4 weeks; subsequent follow-up intervals commonly every 6 months until tube extrusion as clinically indicated.

Document findings at initial post-op visit (within ~4 weeks)
Record subsequent follow-up visits and audiometry/otoscopy results

Prior Authorization

Prior Authorization Recommended for BDET

Prior authorization for balloon eustachian tuboplasty (BDET) is recommended when BDET is proposed for persistent or medically refractory Eustachian tube dysfunction (ETD). Ensure documented failure of medical management before authorization.

Document prior conservative therapies and duration
Confirm symptoms ≥3 months and impact on QOL

Prior Authorization

Confirm BDET Candidate Selection Before Authorization

When requesting authorization for balloon dilation (BDET), confirm patient selection aligns with consensus statements and policy criteria (chronic obstructive ETD, tympanogram B or C or prior tube benefit, absence of contraindicating comorbidities).

Symptoms present ≥3 months and significant effect on QOL
Tympanogram type B or C, or prior tube benefit documented
Rule out contraindications (e.g., patulous ET, nasopharyngeal neoplasm)

Prior Authorization

Prior Authorization for Pediatric BDET When Used After Standard Treatment Failure

For pediatric BDET, prior authorization is reasonable when BDET is proposed after failure of standard treatments (e.g., prior tympanostomy and/or adenoidectomy) for persistent/chronic ETD. Provide documentation of prior interventions and outcomes.

Include prior tympanostomy/adenoidectomy details and outcomes
Document duration of ETD and objective findings

Prior Authorization

Prior Authorization for In‑Office Tula/TDS Procedures

If in‑office tympanostomy placement (Tula/TDS) is proposed, obtain prior authorization when required by the payer. Ensure patient selection and documentation support safe in‑office management.

Confirm patient meets device age and anatomic criteria (not <6 months, no perforation)
Document plan for anesthesia (iontophoresis) and behavioral supports

Prior Authorization

Prior Authorization: FDA‑Approved In‑Office Iontophoresis

FDA‑cleared in‑office iontophoresis (e.g., lidocaine/epinephrine) exists for tympanostomy tube placement, but payer practices vary. Obtain authorization if required and document informed consent discussing limitations and expectations.

Document informed consent and counseling that devices do not eliminate pain
Note any payer-specific prior authorization requirements

Documentation Required

Perform Procedure Only with Governance, Consent, and Audit in Place

Procedure should be performed only with standard arrangements for clinical governance, informed consent, and audit processes in place. Ensure institutional oversight and documentation of governance and consent.

Maintain records of informed consent and clinical governance measures
Follow center-specific perioperative protocols and audit requirements

Documentation Required

Documentation Should Support Diagnosis and Prior Treatment Failure

Documentation must support a diagnosis of obstructive ETD or OME: symptoms present ≥3 months, impact on quality of life, and objective tests (ETDQ‑7, tympanometry, otoscopy, Valsalva). Also document failure of medical management prior to procedural authorization.

Record symptom duration (≥3 months) and QOL impact
Include baseline tympanogram, audiometry (if OME ≥3 months), ETDQ‑7 scores, and prior treatments tried

Step Therapy

No Step Therapy Requirements Described

No explicit step‑therapy requirements are described in this policy fragment. However, the policy and cited guidance emphasize conservative management (medical therapy, autoinflation, Valsalva) prior to surgical interventions in many scenarios.

Document trials of conservative therapies (nasal steroids, autoinflation, Valsalva) when relevant
Note that pediatric trials typically used BDET as second‑line after standard treatments

Denial Risk

Denial Risks — Indication and Documentation Gaps

Failure to meet documented selection criteria, lack of required objective testing, or performing procedures for non‑indicated situations (e.g., single episode OME <3 months) may trigger denials. This policy fragment does not list additional specific denial triggers.

Avoid performing tubes for single episode OME <3 months or recurrent AOM without effusion
Provide clear documentation to mitigate denial risk

Definitions and Key Terms

Myringotomy — definition

DefinitionMyringotomy is an incision of the tympanic membrane to allow ventilation of the middle ear, drainage of middle ear fluid, or to obtain cultures from an infected middle ear.

Clinical usePerformed to relieve middle-ear effusion or to obtain diagnostic middle-ear cultures prior to antimicrobial therapy

Relation to tympanostomy tubesMyringotomy is the surgical step often used to place tympanostomy (ventilation) tubes

Tympanostomy tube — definition

DefinitionTympanostomy tube (ventilation tube/grommet): a small tube placed through the tympanic membrane to ventilate the middle ear and allow drainage of effusion.

IndicationsUsed for persistent OME, recurrent AOM with effusion, or other specified indications per policy Section I

Placement contextsMay be placed in OR under general anesthesia or in-office using iontophoresis and automated delivery systems in selected patients

BDET — definition

DefinitionBalloon dilation of the Eustachian tube (BDET): a trans-nasal endoscopic procedure using a balloon catheter to dilate the cartilaginous portion of the Eustachian tube to improve patency and middle-ear ventilation.

Target populationTypically used for chronic or obstructive Eustachian tube dysfunction refractory to medical therapy

Evidence contextSupported by adult RCTs and systematic reviews showing symptomatic and objective improvements; pediatric evidence more limited

Autoinflation / EarPopper — definition

DefinitionAutoinflation (e.g., EarPopper): a non-invasive device or technique that delivers a regulated stream of air into the nasal cavity during swallowing to transiently open the Eustachian tube and equalize middle ear pressure.

RoleStudied as a short-term, non-surgical option for OME; small RCTs show favorable short-term effects but long-term benefit uncertain

Place in managementConsider trial of autoinflation prior to surgery and document response

Coated tympanostomy tubes — definition

DefinitionCoated tympanostomy tubes: tympanostomy tubes with antimicrobial or surface coatings (e.g., vancomycin, silver oxide, phosphorylcholine) intended to reduce biofilm formation and postoperative otorrhea.

EvidenceIn vitro studies show vancomycin-coated tubes may resist MRSA biofilm; clinical RCT (phosphorylcholine-coated vs uncoated) showed no advantage over uncoated tubes

Policy stanceUse remains investigational for some coatings pending stronger clinical benefit data

Endoscopic trans-nasal balloon dilation of the Eustachian tube — definition

DefinitionEndoscopic trans-nasal balloon dilation of the Eustachian tube: placement of a balloon catheter trans‑nasally into the cartilaginous Eustachian tube under endoscopic guidance to dilate the lumen and improve tubal function.

MechanismDilation aims to increase patency of the cartilaginous portion and reduce inflammation, analogous to balloon sinuplasty concepts

Evidence summaryEarly series and RCTs in adults report symptomatic and objective improvements, though overall evidence varies in quality; further study recommended

BET — Ballon Eustachian Tuboplasty definition

DefinitionBalloon Eustachian Tuboplasty (BET): a transnasal endoscopic procedure using a balloon catheter to dilate the cartilaginous portion of the Eustachian tube to improve patency and middle-ear ventilation.

Consensus criteriaAAO‑HNS consensus targets adults ≥18 with obstructive ETD ≥3 months affecting quality of life as typical BET candidates

Procedure considerationsRequires objective baseline testing (e.g., tympanogram, ETDQ‑7) and failure of medical/pressure therapies prior to BET

Medically refractory/persistent ETD — definition

DefinitionMedically refractory/persistent ETD: Eustachian tube dysfunction with symptoms present for 3 months or longer that has not responded to appropriate medical and pressure therapies and is associated with persistent symptoms or objective abnormal findings (eg, abnormal tympanogram, abnormal ETDQ‑7).

Implication for interventionsDefines patients who may be considered for interventions such as BET or BDET after documentation of prior treatments and objective abnormalities

Objective measuresIncludes abnormal tympanogram type B/C, inability to perform Valsalva, or elevated ETDQ‑7 scores

Candidate population — adults >=18 with obstructive ETD for >=3 months

Candidate population ageAdults aged ≥18 years

Symptom durationObstructive ETD in one or both ears for 3 months or longer

Prior managementSymptoms refractory to well‑conducted medical and pressure therapies and associated with objective abnormal findings

BDET — restated definition (alternate locations in doc)

Definition (restated)BDET: a transnasal endoscopic tuboplasty using a balloon catheter to dilate the cartilaginous portion of the Eustachian tube to improve patency and reduce inflammation.

Clinical noteUsed primarily for chronic or obstructive ETD refractory to medical therapies; evidence includes RCTs and observational studies

Treatment goalsImprove symptoms (ETDQ‑7), normalize tympanograms, restore ability to Valsalva, and reduce middle-ear effusion

ETDQ-7 — definition

DefinitionETDQ‑7: Eustachian Tube Dysfunction Questionnaire‑7, a 7‑item patient‑reported outcome measure used to assess severity and changes in ETD symptoms.

Use in studiesPrimary symptom outcome in multiple BET/BDET trials and systematic reviews

InterpretationChange in ETDQ‑7 score used to quantify symptomatic improvement after intervention

Endoscopic balloon dilation of the Eustachian tube (BDET) — definition

DefinitionEndoscopic balloon dilation of the Eustachian tube (BDET): transnasal endoscopic tuboplasty using a balloon catheter to dilate the cartilaginous portion of the Eustachian tube to improve patency and middle‑ear ventilation.

Evidence noteAdult RCTs (eg, Meyer, Poe) demonstrate superiority to medical management on ETDQ‑7 and tympanogram normalization with durable benefits up to 12 months and beyond

Safety noteProcedures are generally well‑tolerated with low complication rates in reported studies; pediatric evidence is limited and often observational

Trans-tympanic balloon dilatation — definition and evidence note

DefinitionTrans‑tympanic balloon dilatation: a transtympanic approach to dilate the proximal (tympanic‑end) cartilaginous Eustachian tube via the tympanic membrane.

Evidence and limitationsEvidence limited to small case series and cadaver studies with conflicting safety/efficacy findings; theoretical safety concerns (stapes subluxation, cochlear injury) noted in some reports

Policy stanceConsidered investigational/limited evidence; further study required prior to wider clinical use

Tula System (IPS + TDS) — definition

DefinitionTula System (IPS + TDS): an FDA‑cleared system combining iontophoresis to deliver local anesthetic to the tympanic membrane (IPS) and an integrated tube delivery system (TDS) enabling in‑office tympanostomy tube placement.

ComponentsIncludes the anesthetic Tymbion (lidocaine/epinephrine), Tusker Medical tympanostomy tubes, iontophoresis device, and automated tube delivery tools

Intended benefitAllows in‑office tube placement in selected children and adults without general anesthesia

Tula System / iontophoresis — definition and method

Definition / methodIontophoresis: use of a small electrical current to deliver local anesthetic (2% lidocaine with 1:100,000 epinephrine) across the tympanic membrane to produce local anesthesia prior to in‑office tube placement.

Safety dataPharmacokinetic and safety studies in adults demonstrated low systemic lidocaine/epinephrine levels and no device‑ or procedure‑related adverse events

Clinical applicationUsed with an automated tube delivery system (TDS) as part of the Tula System for selected pediatric and adult patients in office settings

FLACC — behavioral observational rating scale definition

DefinitionFLACC: Face, Legs, Activity, Cry, Consolability behavioral observational rating scale used to quantify procedural distress in young children.

Use in studiesApplied to code behavioral distress during in‑office tympanostomy procedures with iontophoresis; reported mean FLACC scores indicated generally mild distress in cohorts studied

Scoring contextFLACC scores reported in Tula‑system behavioral studies (mean ~1.25 overall in one cohort; mean 4.0 during placement for ages 6 months–4 years in another study)

Clinical practice guideline references — citations to Rosenfeld and others

Key guideline referencesRosenfeld RM et al., Clinical practice guideline: Otitis media with effusion (2004, update 2013, and 2022 updates).

Guideline recommendationsWatchful waiting for ~3 months for most children with OME; obtain age‑appropriate audiometry if OME persists ≥3 months; re‑examine at 3–6 month intervals if effusion persists

Additional sourcesAAO‑HNS consensus statements and systematic reviews cited in policy provide context for BDET candidate selection and follow‑up

69420	Myringotomy including aspiration and/or eustachian tube inflation.
69421	Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia.
69424	Ventilating tube removal requiring general anesthesia.
69433	Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia.
69436	Tympanostomy (requiring insertion of ventilating tube), general anesthesia.
0583T	Tympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia.

92550	Tympanometry and reflex threshold measurements.
92567	Tympanometry (impedance testing).

H65.00 - H65.93	Nonsuppurative otitis media.
H66.001 - H66.93	Suppurative and unspecified otitis media.
H69.00 - H69.03	Patulous Eustachian tube.
H71.20 - H71.23	Cholesteatoma of mastoid and unspecified part [middle ear].
H72.10 - H72.13	Attic perforation of tympanic membrane [Pars flaccida].
H90.0 - H91.93	Hearing loss.
Q35.1 - Q37.9	Cleft lip and cleft palate.
T70.0xx+	Otitic barotrauma.

C11.0 - C11.9	Malignant neoplasm of nasopharynx.
J30.1 - J30.9	Allergic rhinitis.
J32.0 - J32.9	Chronic sinusitis.
H69.00 - H69.03	Patulous Eustachian tube.

OpenPayer

Myringotomy and Tympanostomy Tube

Coverage Criteria — Indications, Limitations, and Evidence

Coding — CPT, ICD-10, and Related Codes

Provider Actions — Authorization, Documentation, and Denial Risks

Background and Procedural Context

Definitions and Key Terms

Revision History and Review Dates

69705	Nasopharyngoscopy, surgical, with dilation of eustachian tube; unilateral.
69706	Nasopharyngoscopy, surgical, with dilation of eustachian tube; bilateral.