Balloon Eustachian Tuboplasty (Preauthorization Required)
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Policy governing coverage and preauthorization requirements for balloon dilation of the eustachian tube for treatment of eustachian tube dysfunction (ETD) for Blue Cross Blue Shield - Nebraska members.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Covered when ALL of the following are met
Balloon eustachian tuboplasty may be considered reasonable and necessary when ALL the following diagnostic and prior-therapy criteria are met:
Overall coverage rule
Diagnosis confirmation
- Tympanometry: Abnormal tympanometry findings including negative middle ear pressure
- Tympanic membrane: Retracted tympanic membrane on otoscopic exam
- Symptoms of ETD meeting an ETDQ-7 score of at least 2, for at least 12 weeks
- Valsalva: Inability to perform Valsalva maneuver
Prior therapy failure
- Systemic meds: Systemic antihistamines or decongestants for at least 4 weeks
- Topical decongestants: Nasal topical decongestants with continuous daily use for at least 4 weeks
- Steroids: Nasal steroid spray for at least 4 weeks or completed a course of oral steroids within the previous 90 days
- Interventional treatment with myringotomy or tympanostomy tubes
Balloon eustachian tuboplasty is covered only when ALL specified diagnostic and prior-therapy criteria are satisfied. The policy requires a confirmed diagnosis of eustachian tube dysfunction (ETD) by at least two of the following objective or clinical findings: abnormal tympanometry including negative middle ear pressure, retracted tympanic membrane on otoscopic exam, symptoms meeting an ETDQ-7 score of ≥2 for ≥12 weeks, or inability to perform a Valsalva maneuver. In addition, the patient must have tried and failed at least two of the listed therapies (systemic antihistamines or decongestants for ≥4 weeks; nasal topical decongestants with continuous daily use for ≥4 weeks; nasal steroid spray for ≥4 weeks or a course of oral steroids within the prior 90 days; or interventional treatment with myringotomy/tympanostomy tubes).
The policy’s Quick Code Search requires entry of a paired procedure and diagnosis code to determine whether a code pair will be approved, denied, or held for review. Providers must enter the procedure code first and then the diagnosis code and click “Add Code Pair”; absence of an appropriate procedure–diagnosis code pair may result in the request being held for review or denied.
Any use of balloon eustachian tuboplasty that does not meet all of the policy’s listed criteria — both the diagnostic confirmation (at least two findings) and the documented failure of at least two prior therapies — is considered not reasonable and necessary and is not covered under this policy.
Coding
| C9745 | Nasal endo eustachian tube |
Provider Actions and Requirements
Preauthorization required — submit diagnostic and therapy documentation
Preauthorization is required for balloon eustachian tuboplasty; submit documentation demonstrating that ALL policy diagnostic criteria are met and that the patient has tried and failed at least two listed therapies.
- Documentation must show diagnosis of ETD confirmed by at least two findings (see Required clinical documentation).
- Documentation must show failure of at least two therapies listed in the policy prior to approval.
Preauthorization required — use Quick Code Search and add code pair
Use the policy Quick Code Search when requesting preauthorization: enter the procedure code then the diagnosis code and click 'Add Code Pair' so the tool can indicate whether the pair will be approved, denied, or held for review.
- Enter at least the first three characters of the diagnosis code when prompted.
- Both a procedure code and a diagnosis code are required to run the Quick Code Search.
Prior conservative therapies required — document ≥2 failed therapies
Prior to approval, the patient must have trialed and failed at least two of the specified medical or interventional treatments listed in the policy.
- Examples include: systemic antihistamines or decongestants for ≥4 weeks; nasal topical decongestants daily for ≥4 weeks; nasal steroid spray for ≥4 weeks or a course of oral steroids within the prior 90 days; or interventional treatment with myringotomy or tympanostomy tubes.
High-priority: include all required diagnostic and therapy evidence
Ensure preauthorization submission includes the policy-required diagnostic confirmation and prior-therapy documentation; missing required elements may result in the request being held for review or denied.
- Confirm inclusion of both diagnostic findings and records of the two failed therapies in the request.
Required clinical documentation — confirm ETD with ≥2 findings and prior therapy records
Document diagnostic confirmation of ETD with at least two of the specified findings and include records of prior conservative and interventional therapies attempted and failed.
- Required findings (at least two): abnormal tympanometry including negative middle ear pressure; retracted tympanic membrane on otoscopic exam; ETDQ-7 score ≥2 for ≥12 weeks; inability to perform Valsalva maneuver.
- Provide dates and duration of each prior therapy (e.g., ≥4 weeks for systemic antihistamines/decongestants, topical decongestants, or nasal steroid spray; timing of myringotomy/tympanostomy if performed).
Procedure + diagnosis code pair required for Quick Code Search
When using the Quick Code Search for preauthorization, providers must enter both a procedure code and a diagnosis code; the tool uses listed code pairs to indicate approval, denial, or hold for review.
Coverage limited to specific ETD criteria — other indications not covered
Coverage is limited to balloon eustachian tuboplasty performed for ETD that meets ALL policy diagnostic and prior-therapy criteria; BDET for other indications is considered not reasonable and necessary.
- Any use of BDET that does not meet the required diagnostic confirmation and prior-therapy failures is considered not reasonable and necessary.
Missing procedure/diagnosis code pair may trigger denial or hold
Failure to submit both a procedure code and a diagnosis code pair when required by the Quick Code Search may result in the code pair being held for review, denied, or not processed.
- Ensure both codes are entered and 'Add Code Pair' is clicked so the tool can evaluate the pair.
Definitions
Background
Eustachian tube dysfunction (ETD) occurs when the cartilaginous eustachian tube fails to open and/or close properly, commonly because of inflammation or anatomic factors. Typical symptoms include aural fullness, ear pressure, muffled hearing, tinnitus, and sometimes vertigo. Chronic obstructive ETD can lead to middle ear disease. Balloon dilation of the eustachian tube (balloon eustachian tuboplasty) is intended to improve tubal patency by mechanically dilating the cartilaginous portion of the tube.
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