ModifiedArkansas Blue Cross and Blue ShieldPolicy 2018007

Balloon Dilation of the Eustachian Tube

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This policy governs restricted coverage for balloon dilation of the Eustachian tube using a U.S. Food and Drug Administration-approved device for adults with chronic obstructive Eustachian tube dysfunction when documented clinical, diagnostic, treatment-response, reversibility, and exclusion criteria are met.

Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyBalloon Dilation of the Eustachian Tube

Policy CodePolicy 2018007

Change TypeRestricted coverage added

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documenting that the FDA-approved BDET device will be used and that all restricted-coverage criteria are met.

SourceLink

POLICY UPDATE CHANGES

Restricted coverage was added for BDET for chronic obstructive Eustachian tube dysfunction when specified clinical criteria are met.

18+Minimum patient age

12 moMinimum symptom duration

4–6 wkNasal steroid trial when indicated

2Required abnormal diagnostic findings

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ModifiedArkansas Blue Cross and Blue ShieldPolicy 2018007

Balloon Dilation of the Eustachian Tube

Customize your policy alerts

Sign up for arkansas_blue_cross_blue_shield Policy 2018007 alerts

Get alerted when Policy 2018007 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyBalloon Dilation of the Eustachian Tube

Policy CodePolicy 2018007

Change TypeRestricted coverage added

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documenting that the FDA-approved BDET device will be used and that all restricted-coverage criteria are met.

SourceLink

POLICY UPDATE CHANGES

Restricted coverage was added for BDET for chronic obstructive Eustachian tube dysfunction when specified clinical criteria are met.

18+Minimum patient age

12 moMinimum symptom duration

4–6 wkNasal steroid trial when indicated

2Required abnormal diagnostic findings

Balloon Dilation Coverage Requirements

Restricted coverage for balloon dilation of the Eustachian tube

Restricted coverage is available when all applicable criteria are met.

Restricted BDET coverage

Adult chronic obstructive ETD: The individual is age 18 years or older and has symptoms of obstructive ETD in one or both ears for 12 months or longer that significantly affect quality of life or functional health status.Age ≥ 18; symptoms ≥ 12 months
Symptoms may include aural fullness, aural pressure, otalgia, and/or hearing loss; both aural fullness and aural pressure must be present.
Comprehensive diagnostic assessment: The individual has undergone patient-reported questionnaires, history and physical examination, tympanometry when the tympanic membrane is intact, nasal endoscopy, and comprehensive audiometry, with an abnormal tympanogram and an abnormal tympanic membrane.Abnormal tympanogram: Type B or C
Abnormal tympanic membrane findings may include retraction, effusion, perforation, or another abnormality identified on examination.
Failure of medical management: The individual has failed to respond to appropriate medical management of potential co-occurring conditions, if present, such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux.4–6 weeks of nasal steroid spray when indicated
Alternative causes excluded: Other causes of aural fullness, including temporomandibular joint disorders, extrinsic obstruction of the Eustachian tube, superior semicircular canal dehiscence, and endolymphatic hydrops, have been ruled out.
Prior tympanostomy tube response when applicable: If the individual has a history of tympanostomy tube placement, obstructive ETD symptoms should have improved while the tubes were patent.
This criterion applies only when there is a history of tympanostomy tube placement.
Procedure eligibility: The individual does not have patulous ETD or another contraindication to the procedure, and the ETD has been shown to be reversible.
See Policy Guidelines for contraindications and reversibility assessment.
Continuous symptoms and no prior BDET: Symptoms are continuous rather than episodic, and the individual has not had a previous BDET procedure.
Symptoms occurring only in response to barochallenge, such as pressure changes while flying, are episodic.

FDA-approved device: BDET must be performed with a device approved by the U.S. Food and Drug Administration for treatment of chronic obstructive ETD.

Restricted coverage does not apply when the individual has patulous Eustachian tube dysfunction (ETD), another contraindication to balloon dilation of the Eustachian tube (BDET), or ETD that has not been shown to be reversible. Coverage also excludes episodic symptoms, including symptoms occurring only with barochallenge such as pressure changes while flying, and any individual who has undergone a previous BDET procedure.

Documentation and Authorization Requirements

Prior Authorization

Demonstrate All BDET Coverage Criteria

Prior authorization is required. Submit documentation demonstrating that every restricted-coverage criterion for BDET is satisfied before performing the procedure.

Use a device approved by the U.S. Food and Drug Administration for treatment of chronic obstructive eustachian tube dysfunction (ETD).
Document that all applicable clinical, diagnostic, medical-management, reversibility, and procedure-history requirements described below are met.

Step Therapy

Failed Medical Management

Document failure to respond to appropriate medical management of potential co-occurring conditions before BDET. When indicated, this must include a 4- to 6-week course of nasal steroid spray.

Address applicable conditions such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux.
Document the treatments provided and the individual's response or lack of response.

Chronic Obstructive Eustachian Tube Dysfunction

This policy addresses chronic obstructive Eustachian tube dysfunction, which may cause aural fullness, aural pressure, otalgia, and hearing loss. BDET is considered for adults only after a comprehensive diagnostic assessment, management of potentially co-occurring conditions, exclusion of alternative causes of aural fullness, and confirmation that the ETD is reversible and continuously symptomatic.

Documentation Required

Clinical and Diagnostic Documentation

The record must establish that the individual is an adult with chronic, functionally significant obstructive ETD and must include a comprehensive diagnostic assessment.

Age 18 years or older.
Symptoms in one or both ears for 12 months or longer that significantly affect quality of life or functional health status.
Required symptoms include aural fullness and aural pressure; otalgia and/or hearing loss may also be present.
Comprehensive assessment including patient-reported questionnaires, history and physical examination, tympanometry when the tympanic membrane is intact, nasal endoscopy, and comprehensive audiometry.
Diagnostic findings of an abnormal tympanogram (Type B or C) and an abnormal tympanic membrane, such as retraction, effusion, perforation, or another abnormality identified on examination.
Other causes of aural fullness, including temporomandibular joint disorder, extrinsic eustachian tube obstruction, superior semicircular canal dehiscence, and endolymphatic hydrops, must be ruled out.

Denial Risk

Failure to Meet Restricted-Coverage Criteria

BDET is not eligible for restricted coverage when any required criterion is absent or an exclusion applies. The procedure should not proceed under this coverage policy unless all criteria are documented.

Individual is younger than 18 years.
Obstructive ETD symptoms have been present for less than 12 months or do not significantly affect quality of life or functional health status.
Aural fullness and aural pressure are not both present, or required diagnostic findings are absent, including the abnormal Type B or C tympanogram and abnormal tympanic membrane finding.
Required comprehensive diagnostic assessment, appropriate medical management, or rule-out evaluation for other causes of aural fullness has not been completed or documented.
Failure of appropriate management of co-occurring conditions, including nasal steroid treatment when indicated, is not demonstrated.
ETD is nonreversible, patulous, or another contraindication to the procedure is present.
Symptoms are episodic rather than continuous, such as occurring only with barochallenge.
For individuals with prior tympanostomy tubes, symptoms did not improve while the tubes were patent.
A previous BDET procedure has been performed.