CurrentBlue Cross Blue Shield - KansasPolicy N/A

Balloon Dilation of the Eustachian Tube

This policy governs coverage criteria for balloon dilation of the eustachian tube for members of Blue Cross and Blue Shield of Kansas, specifying clinical eligibility, diagnostic requirements, contraindications, and when the procedure is considered investigational.

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyBalloon Dilation of the Eustachian Tube

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 3, 2021

Next Review DateN/A

Key ActionObtain prior authorization confirming age ≥22, symptom duration ≥12 months, objective abnormal tympanogram (Type B or C), and documentation of failed medical management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12 monthsrequired symptom duration

Type B or Crequired abnormal tympanogram types

≥22minimum age for covered BDET

2–3RCTs discussed

2procedure codes listed

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Coverage and Medical Necessity Criteria

Medically necessary criteria

Covered when ALL of the following are met

Age: Adult age 22 years and older>=22 years

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Symptom duration: Symptoms of obstructive ETD (aural fullness and pressure must be present; may include otalgia and/or hearing loss) for 12 months or longer in one or both ears that significantly affects quality of life or functional status>=12 months

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Diagnostic assessment: Comprehensive diagnostic assessment including patient‑reported questionnaires, history and physical exam, tympanometry if tympanic membrane is intact, nasal endoscopy, and comprehensive audiometry with abnormal tympanogram (Type B or C) or abnormal tympanic membrane (retracted membrane, effusion, perforation, or other abnormality)abnormal tympanogram Type B or C or abnormal TM

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Failure of medical management: Failure to respond to appropriate medical management of potential co‑occurring conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux), including 4–6 weeks of a nasal steroid spray if indicatedtrial completed and failed

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Rule out other causes: Other causes of aural fullness (temporomandibular joint disorders, extrinsic eustachian tube obstruction, superior semicircular canal dehiscence, endolymphatic hydrops) have been ruled out

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Prior tympanostomy response: If prior tympanostomy tubes were placed, symptoms should have improved while tubes were patent

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No contraindications: No patulous eustachian tube dysfunction or other contraindication to BDET

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Reversibility demonstrated: ETD shown to be reversible (e.g., ability to Valsalva with symptom relief; Valsalva produces temporary normalization of tympanogram to Type A; or provider visualization of lateral TM movement on otoscopy with Valsalva)

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Continuous symptoms: Symptoms are continuous rather than episodic (not limited to barochallenge)

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No prior BDET: No history of a prior BDET procedure

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Coverage when ALL of the following are met

Covered when ALL of the following are met (criteria reflect enrollment criteria of major randomized trials):

Patient symptoms: Persistent patient‑reported symptoms of Eustachian tube dysfunction documented (trial eligibility used ETDQ‑7: mean item score ≥2.1 or total score ≥14.5)ETDQ-7 mean ≥2.1 or total ≥14.5

Derived from trial eligibility (Poe et al., Meyer et al.)

Objective abnormality: Abnormal middle ear functional testing documented prior to procedure (abnormal tympanometry Type B or C)Tympanogram Type B or C

Required objective measure in Poe et al. trial

Prior medical management: Failure of medical management documented, e.g., minimum 4 weeks daily intranasal steroid spray or at least one course of oral steroid as required in trials

Initial therapy / Coverage criteria

Covered when ALL of the following are met

Duration and impact: Obstructive ETD for 3 months or longer in one or both ears that significantly affects quality of life or functional health status>=3 months

Reflects clinical input and AAO‑HNS consensus defining target population

Diagnostic assessment: Comprehensive diagnostic assessment performed including history and physical exam, tympanometry if tympanic membrane is intact, nasopharyngoscopy, and comprehensive audiometry

AAO‑HNS and clinical input recommend multifaceted assessment

Failure of medical management: Failure to respond to appropriate medical management of co‑occurring conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux), including a 4–6 week trial of nasal steroid spray when indicated4–6 weeks trial when indicated

Exclusions: BDET should not be performed in individuals with patulous eustachian tube dysfunction or when ETD is due to identifiable extrinsic reversible or irreversible causes. Examples of extrinsic causes include craniofacial syndromes (including cleft palate spectrum), neoplasms causing extrinsic obstruction, history of radiation to the nasopharynx, enlarged adenoids, nasopharyngeal mass, neuromuscular disorders causing ineffective ET opening, and active systemic mucosal or autoimmune inflammatory disease affecting the nasopharyngeal mucosa.

Additional exclusions: patients with aural fullness but normal exam and tympanogram, and individuals with chronic and severe atelectatic ears should not be considered for BDET. The policy also references trial exclusion scenarios (e.g., anatomic conditions requiring adjunctive procedures) that would preclude consideration for the procedure.

Trial enrollment and procedural caveats: major randomized trials excluded patients with anatomy that would require adjunctive surgical procedures, and excluded cases where concomitant nasal/sinus or ear procedures were planned on the same day as BDET. Trials also excluded recent major head/neck surgery within 4 months, active acute otitis media, tympanic membrane perforation, tympanosclerosis, internal carotid artery dehiscence, pregnancy, and current participation in other device or drug studies.

Clinical implication: when anatomical findings suggest the need for adjunctive repair (for example, significant nasopharyngeal mass or other anatomic obstruction) or when other ENT procedures are planned the same day, BDET was not studied and such situations should be managed per specialist judgment rather than assumed eligible for standalone BDET.

Contraindication: BDET is contraindicated for patients diagnosed with patulous eustachian tube dysfunction. Patulous ETD is suggested by symptoms such as autophony, audible respiration, pulsatile tinnitus, and/or aural fullness; these patients should not be considered for balloon dilation.

When coverage criteria are not met: balloon dilation of the eustachian tube (BDET) is considered experimental/investigational and not covered if the policy's specified criteria (including required diagnostic findings, documented failure of medical management, absence of contraindications, and other enrollment elements) are not satisfied.

Procedures performed without required documentation: BDET performed without documentation of failed medical therapy (for example, a minimum trial of topical intranasal steroid for ≥4 weeks or at least one course of oral steroid when indicated) and without objective abnormal middle ear testing (e.g., tympanometry showing Type B or C) do not meet the enrollment criteria used in randomized trials and are not supported by those studies.

Limitations and appropriate indications: BDET is indicated only for chronic ETD that is refractory to medical treatment. Guidance and evidence summaries note that the procedure is not effective in all patients and there is limited evidence on the benefit of repeat procedures. Because of these evidence limitations, careful patient selection and documentation of prior medical management and objective abnormalities are required before offering BDET.

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required to confirm that all coverage criteria are met before scheduling BDET. The request must document patient age (≥22 years), symptom duration (≥12 months), and that a comprehensive diagnostic assessment was completed.

Adult age ≥22 years documented
Symptoms (aural fullness/pressure, otalgia, hearing loss) for ≥12 months documented
Comprehensive diagnostic assessment documented (history & physical, patient-reported questionnaires such as ETDQ-7, tympanometry if TM intact, nasal endoscopy/nasal exam, and audiometry)

Prior Authorization

Prior Authorization — Verify Failed Medical Therapy and Objective Findings

Prior authorization must verify failed medical therapy and objective abnormalities prior to approval. Provide documentation of prior medical management attempts and objective testing results showing ETD.

Documented failure of appropriate medical management for co-occurring conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux)
Minimum topical intranasal steroid trial of 4–6 weeks (if indicated) or history of an oral steroid course as used in pivotal trials
Objective abnormality: abnormal tympanogram (Type B or C) or abnormal tympanic membrane on exam (retraction, effusion, perforation)

Billing Rule

Coding and Prior Authorization / Billing

Include applicable CPT codes on the prior authorization request. Listing of codes does not guarantee member coverage — confirm benefits under the member's contract.

CPT 69705 — surgical nasopharyngoscopy with dilation of eustachian tube, unilateral
CPT 69706 — surgical nasopharyngoscopy with dilation of eustachian tube, bilateral
Inclusion of these codes is informational; coverage is contingent on meeting policy criteria and member contract benefits

Documentation Required

Medical Management Required Before BDET

Medical management failure is required before BDET; ensure management of treatable underlying conditions and document lack of response.

Treat underlying/treatable conditions (systemic decongestants, antihistamines, intranasal steroid sprays, reflux management) prior to BDET
Document specific therapies tried and duration (e.g., intranasal steroid spray 4–6 weeks when indicated)
Confirm co-occurring conditions were addressed and symptoms persisted despite therapy

Definitions and Key Concepts

Balloon dilation of the eustachian tube (BDET) — definition & technique

DefinitionMinimally invasive transnasal endoscopic tuboplasty that introduces a saline-filled balloon catheter into the cartilaginous eustachian tube to dilate it

Typical techniqueBalloon catheter is introduced via the nose under endoscopic guidance; balloon is inflated and pressure maintained for ≤2 minutes, then deflated and removed

Anesthesia and concomitant proceduresProcedure is usually performed under general anesthesia and may be done alone or with other ENT procedures (e.g., adenoidectomy, septoplasty, myringotomy/tympanostomy)

ETDQ-7 — description and diagnostic thresholds

InstrumentETDQ-7: validated 7-item patient‑reported questionnaire assessing ETD symptom severity

Diagnostic thresholdsTotal score ≥14.5 or mean item score ≥2.1 indicate ETD

Symptoms assessedPressure, pain, feeling clogged, cold/sinusitis problems, crackling/popping, ringing, muffled hearing

ETDQ-7 — diagnostic thresholds and MCID

Diagnostic thresholds (repeat)Total score ≥14.5 or mean item score ≥2.1 indicate ETD

MCID0.5 point improvement is considered the minimal clinically important difference

NormalizationMean item score <2.1 or total <14.5 denotes normalization

Tympanometry types

Type ANormal middle ear and eustachian tube function

Type BPoor tympanic membrane mobility ('flat' tympanogram) — indicates middle ear fluid or reduced mobility

Type CNegative middle ear pressure — suggests ET dysfunction with retraction or negative pressure

Valsalva maneuver — definition & interpretation

Valsalva maneuver — definitionPatient exhales while closing the nose and mouth to direct air through the eustachian tube to help it open

Positive resultAbility to perform maneuver when needed (may produce symptom relief)

Use in assessmentMay demonstrate reversibility (e.g., temporary normalization of tympanogram or TM lateral movement on otoscopy) and is used as objective evidence

Obstructive Eustachian Tube Dysfunction (ETD) — definition

Definition used in policyObstructive ETD: symptoms in one or both ears for 3 months or longer that significantly affect quality of life or functional health status

Required assessmentDiagnosis requires comprehensive assessment including otoscopy, audiometry, and nasal endoscopy

Prioritize medical managementMedical treatment of co-occurring conditions (e.g., allergic rhinitis, rhinosinusitis) is indicated prior to BDET

BDET contraindications and potential risks

Contraindication (primary)Patulous eustachian tube dysfunction is a contraindication to BDET

Potential risksBleeding, scarring, infection, development of patulous ETD, and/or the need for additional procedures

Pre-procedure checkPatients should be assessed to exclude patulous ETD and other anatomic or active disease contraindications

OpenPayer

Balloon Dilation of the Eustachian Tube

Coverage and Medical Necessity Criteria

Coding and Diagnostic Thresholds

Prior Authorization, Documentation, and Operational Requirements

Definitions and Key Concepts

Background and Evidence Summary

69705	Surgical nasopharyngoscopy with dilation of eustachian tube unilateral.
69706	Surgical nasopharyngoscopy with dilation of eustachian tube bilateral.