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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)Baylor Scott & White BDET Coverage Prior Auth | Op…
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    CurrentBaylor Scott & White Health PlanPolicy 300

    Balloon Dilation of the Eustachian Tube

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    Medical coverage policy governing when Baylor Scott & White Health Plan considers balloon dilation of the Eustachian tube (BDET) medically necessary or investigational for members; applies to providers submitting claims and seeking prior authorization.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyBalloon Dilation of the Eustachian Tube
    Policy CodePolicy 300
    Change TypeNo material change
    Effective DateMar 1, 2026
    Last ReviewJan 22, 2026
    Next Review DateJan 22, 2027
    Key ActionObtain prior authorization and document age, symptom duration (>=6 months), prior treatments, tympanogram or prior tympanostomy benefit before BDET.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Once per earfrequency limit
    >= 18minimum patient age

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    >= 6 mosymptom duration requirement
    Prior authauthorization
    With middle ear surgeryinvestigational condition

    Coverage Criteria for Balloon Dilation of the Eustachian Tube (BDET)

    Medically necessary (BDET)

    Covered when ALL of the following are met:

    Main medical necessity criteria: 1. Age 18 years or older;

    Requirement 1 per policy

    Symptom requirement: 2. Any of the following symptoms experienced continuously for 6 months or greater and significantly impacting quality of life or functional health status: aural fullness/pressure, otalgia, hearing loss, tinnitus, or intolerance to barometric changes;>= 6 months

    Requirement 2 per policy

    Conservative therapy requirement: 3. If indicated, failed to respond to surgical or appropriate medical management of known causes of obstructive ETD (for example, at least 4–6 weeks of nasal steroids or proton pump inhibitors for conditions such as rhinosinusitis, allergic/nonallergic rhinitis, laryngopharyngeal reflux, mass lesions, or adenoid hypertrophy);

    Requirement 3 per policy

    Objective middle ear finding: 4. Abnormal tympanogram (Type B or C) OR history of tympanostomy tube placement with improvement of ETD symptoms while tubes were patent;

    Requirement 4 per policy

    Contraindications absence: 5. Absence of co-morbid conditions or contraindications to BDET (including, but not limited to, patulous eustachian tube; extrinsic reversible or irreversible causes of ETD such as craniofacial syndromes, neoplasms causing extrinsic obstruction, prior radiation to the nasopharynx, enlarged adenoids, nasopharyngeal mass, neuromuscular disorders causing ineffective ET opening, active systemic mucosal or autoimmune inflammatory disease affecting the nasopharynx/ET mucosa, or carotid abnormalities).

    Requirement 5 per policy

    Experimental / Investigational

    Not covered / investigational

    Investigational conditions: BDET performed with tympanoplasty or other middle ear surgeries; trans-tympanic balloon dilatation of the Eustachian tube for treatment of ETD and chronic ear disease; and for all indications other than those explicitly listed as medically necessary.

    Policy indicates these are experimental and investigational

    Baylor Scott & White Health Plan does not cover balloon dilation of the Eustachian tube when it is performed concurrently with tympanoplasty or other middle ear surgical procedures. The policy explicitly states that BDET performed in conjunction with tympanoplasty or other middle ear surgeries is considered experimental and investigational and therefore not covered.

    Trans‑tympanic balloon dilatation of the Eustachian tube is considered experimental and investigational for the treatment of obstructive ETD and chronic ear disease because the policy finds that the effectiveness of this trans‑tympanic approach has not been established. Claims for trans‑tympanic balloon dilation for these indications are therefore not covered.

    Coding and Clinical Parameters

    CPT Codes Not Covered / CoveredCPT
    69705Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral
    69706Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral
    Potentially applicable ICD-10 codes (inclusive list note)ICD-10
    H65.21 - H65.23Chronic nonsuppurative otitis media (range listed)
    H66.001 - H66.006, H66.011, H66.012Suppurative and unspecified otitis media (range/list)
    H67.1 - H67.3Otitis media in diseases classified elsewhere
    H68.001 - H68.003, H68.009, H68.021 - H68.023, H68.029Unspecified and chronic eustachian salpingitis (listed codes)
    H69.80 - H69.83, H69.90 - H69.93Other specified disorders of eustachian tube (listed codes)
    H72.01 - H72.03, H72.11 - H72.13, H72.2X1 - H72.2X3, H72.811 - H72.813, H72.821 - H72.823, H72.91 - H72.93Perforation of tympanic membrane (listed codes)
    H90.0, H90.11, H90.12, H90.A11, H90.A12Conductive hearing loss (listed codes)
    H90.3, H90.41, H90.42, H90.A21, H90.A22Sensorineural hearing loss (listed codes)
    H90.6, H90.71, H90.72Mixed conductive and sensorineural hearing loss (listed codes)
    inv-07: Symptom duration — >= 6 months
    Required symptom duration>= 6 months (continuous) with significant impact on quality of life or functional status
    Context in criteriaAny qualifying symptom (aural fullness/pressure, otalgia, hearing loss, tinnitus, intolerance to barometric changes) must be present continuously for >= 6 months
    Documentation expectationSymptom duration (>= 6 months) should be documented in prior authorization/clinical records
    inv-08: Minimum age — >= 18 years
    Minimum age for BDET>= 18 years
    Policy applicationAge requirement is step 1 of medical necessity:

    Provider Requirements and Authorization

    Prior Authorization

    Prior authorization required

    Prior authorization is required before balloon dilation of the Eustachian tube (BDET). Authorization will be granted only when the individual meets all medical necessity criteria listed in the policy.

    Step Therapy

    Conservative therapy requirement

    Patient must have undergone and failed appropriate medical or surgical management of known causes of obstructive ETD prior to consideration of BDET, for example at least 4–6 weeks of nasal steroids or proton pump inhibitors when indicated.

    • Targets include management of rhinosinusitis, allergic/nonallergic rhinitis, laryngopharyngeal reflux, mass lesions, or adenoid hypertrophy.

    Background

    Balloon dilation of the Eustachian tube (BDET) is a minimally invasive, transnasal endoscopic procedure in which a balloon is introduced into the cartilaginous portion of the Eustachian tube and inflated to dilate the lumen. It may be performed in an operating room under general anesthesia or in an office setting with local anesthesia with the goal of improving ventilation and drainage of the middle ear and relieving symptoms of obstructive ETD.

    Definitions

    inv-14: Obstructive eustachian tube dysfunction (ETD) — definition and clinical features (low importance)
    DefinitionObstructive eustachian tube dysfunction (ETD): inability of the Eustachian tube to ventilate the middle ear, drain secretions, or protect the middle ear
    Common clinical featuresEar pain/discomfort, aural fullness or pressure, hearing difficulties (hearing loss), tinnitus, intolerance to barometric changes, recurrent middle ear infections
    Pathophysiology noteOften due to pathology in the cartilaginous portion of the Eustachian tube; structural (narrow tube, adenoid hypertrophy) and inflammatory (allergic rhinitis, sinusitis, frequent URI) causes are common
    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyBalloon Dilation of the Eustachian Tube
    Policy CodePolicy 300
    Change TypeNo material change
    Effective DateMar 1, 2026
    Last ReviewJan 22, 2026
    Next Review DateJan 22, 2027
    Key ActionObtain prior authorization and document age, symptom duration (>=6 months), prior treatments, tympanogram or prior tympanostomy benefit before BDET.
    SourceLink
    On This Page
    Coverage Criteria for Balloon Dilation of the Eustachian Tube (BDET)Coding and Clinical ParametersProvider Requirements and AuthorizationBackgroundDefinitions
    Frequency noteWhen age criterion met, coverage consideration also limited to once per ear, lifetime (see policy)
    Documentation Required

    Required clinical documentation

    Include documentation of symptom duration and type, prior medical and surgical treatments, tympanogram results or history of tympanostomy tube benefit, and absence of listed contraindications when submitting for BDET.

    • Symptom duration: continuous symptoms for ≥6 months.
    • Symptom types: aural fullness/pressure, otalgia, hearing loss, tinnitus, intolerance to barometric changes.
    • Prior treatments: medical (e.g., 4–6 weeks of nasal steroids or PPIs) and any relevant surgical interventions.
    • Objective findings: abnormal tympanogram (Type B or C) OR history of tympanostomy tube placement with symptom improvement while tubes were patent.
    Denial Risk

    Denial triggers for BDET

    Claims or authorization requests may be denied if medical necessity criteria are not met, or if BDET is performed with concurrent tympanoplasty or other middle ear surgery.

    • Failure to meet age requirement (must be ≥18 years).
    • Symptoms not experienced continuously for ≥6 months or not significantly impacting quality of life.
    • Absence of abnormal tympanogram (Type B or C) and no history of tympanostomy tube benefit.
    • No documentation of failed appropriate medical or surgical management.
    • Procedure performed with tympanoplasty or other middle ear surgeries — considered experimental/investigational.