Balloon Dilation of the Eustachian Tube (BDET)
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Clinical coverage policy for balloon dilation of the eustachian tube (BDET) for treatment of chronic obstructive eustachian tube dysfunction (ETD), including adult and pediatric guidance, diagnostic and contraindication requirements, and when the procedure is investigational.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medically Necessary Criteria for BDET (Adults and general)
Covered when ALL of the following are met:
See Policy Guidelines
See Policy Guidelines
Pediatric Eligibility (Ages 8-17) with Acclarent AERA system
Covered when ALL of the following are met:
Device-specific FDA clearance (Acclarent AERA)
Investigational
Medical necessity criteria
Covered when ALL of the following are met
Policy and FDA pediatric indication specify refractory to medical management
Usually performed under general anesthesia
Balloon dilation of the eustachian tube is contraindicated in individuals with patulous ETD. Patulous ETD is suggested by symptoms such as autophony of voice, audible respirations, pulsatile tinnitus, and/or aural fullness. The procedure is also contraindicated for individuals with extrinsic reversible or irreversible causes of ETD, including but not limited to craniofacial syndromes (such as cleft palate spectrum), neoplasms causing extrinsic obstruction, prior radiation to the nasopharynx, enlarged adenoids, nasopharyngeal masses, neuromuscular disorders causing ineffective tubal opening, and active systemic mucosal or autoimmune inflammatory disease affecting the nasopharyngeal mucosa (for example, Samter’s triad, Wegener’s disease, or mucosal pemphigus) that is not in remission.
The policy excludes individuals who present with aural fullness but a normal otologic examination and normal tympanogram from consideration for balloon dilation. Additionally, patients with chronic and severe atelectatic ears are not appropriate candidates for BDET per the documented contraindications.
Alternative surgical procedures that provide an alternate route for middle ear ventilation—such as myringotomy with tympanostomy tube placement or eustachian tuboplasty—do not correct the underlying eustachian tube functional deficit. The policy notes limited evidence and no randomized controlled trials supporting these techniques for treating ETD and highlights their associated risks (for example, infection, tympanic membrane perforation, otorrhea, and the potential need for repeated tube placements).
Use of balloon dilation of the eustachian tube when the policy’s required diagnostic and clinical criteria are not met is considered investigational / not medically necessary because there is insufficient evidence to demonstrate a net health benefit.
The policy cautions against using alternative surgical techniques as definitive treatment for ETD when those procedures do not address the eustachian tube’s functional problem. Such surgical approaches lack RCT evidence for this indication and carry procedure-specific risks; therefore they should not be considered equivalent substitutes for interventions shown to address ETD function.
Billing and Diagnosis Codes
| No codes listed |
| H68.001 | Unspecified Eustachian salpingitis, right ear |
| H68.002 | Unspecified Eustachian salpingitis, left ear |
| H68.003 | Unspecified Eustachian salpingitis, bilateral |
| H68.009 | Unspecified Eustachian salpingitis, unspecified ear |
| H68.021 | Chronic Eustachian salpingitis, right ear |
| H68.022 | Chronic Eustachian salpingitis, left ear |
| H68.023 | Chronic Eustachian salpingitis, bilateral |
| H68.029 | Chronic Eustachian salpingitis, unspecified ear |
| H68.121 | Intrinsic cartilaginous obstruction of Eustachian tube, right ear |
| H68.122 | Intrinsic cartilaginous obstruction of Eustachian tube, left ear |
Provider Requirements, Authorization, and Documentation
Check product/program-specific authorization rules
This policy applies only to certain Capital Blue Cross programs and products; benefit variations may affect whether prior authorization or coverage rules apply. Refer to program-specific manuals (for example, the FEP PPO medical policy manual) for product-specific requirements.
Prior authorization may be required for CPT 69705 / 69706
Procedure codes 69705 and 69706 are listed in the coding section and coverage is determined by medical necessity and member benefit terms; prior authorization may be required per the member's plan.
- Codes noted in coding section may not guarantee coverage; see member benefit for prior authorization requirements.
Require documented failure of appropriate medical management before BDET
Document that the member failed to respond to appropriate medical management of potential co-occurring conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux) before BDET is performed.
- Include duration and details of prior medical therapy.
- Specifically document trial of therapies for co-occurring conditions and response.
Document prior medical therapy attempts (including nasal steroid trial)
Document prior medical therapy attempts leading to surgical consideration — the policy requires failure of medical management (including a 4–6 week trial of nasal steroid spray when indicated) prior to balloon dilation.
- Record duration and type of therapies tried (e.g., 4–6 weeks nasal steroid spray if indicated).
- Note that BDET is considered after medical management has failed.
Document a comprehensive diagnostic assessment
Provide a comprehensive diagnostic assessment in the medical record, including patient-reported questionnaires, history and physical exam, tympanometry (if tympanic membrane intact), nasal endoscopy, and comprehensive audiometry with documented findings.
- Include tympanogram results (Type B or C) or tympanic membrane abnormalities (retraction, effusion, perforation).
- Record nasal endoscopy and audiometry findings.
Document symptom duration (>=3 months) and failed medical management
Document symptom duration and prior medical management: persistent obstructive ETD symptoms (aural fullness and pressure required) for 3 months or longer and failure of medical management must be recorded.
- Specify symptom duration (>= 3 months) and that symptoms significantly affect quality of life or function.
- Note whether symptoms are continuous rather than episodic (not only with barochallenge).
Document medical necessity and confirm benefit-specific coverage
Document the medical necessity for the procedure; include diagnostic evidence and treatments tried. The coding list may not be all-inclusive and identification of a code does not denote coverage—final payment depends on member benefit and medical necessity determinations.
- Include justification tying documented findings to medical necessity.
- Verify member benefit and eligibility; do not assume code listing equals coverage.
Investigational/denial risk if policy criteria or benefit requirements unmet
BDET is investigational and may be denied if the required diagnostic and clinical criteria in the policy are not met; coverage and payment are also subject to the member's benefit program, eligibility on the date of service, and medical necessity determinations.
- Failure to meet criteria (diagnostics, symptom duration, prior medical management) can lead to a determination of investigational/not medically necessary and denial.
- Confirm member benefit eligibility and obtain any required prior authorization to reduce denial risk.
Confirm member benefit, eligibility, and medical necessity for coverage/payment
Coverage and payment depend on the member's benefit program, eligibility on the date of service, and a determination that the service is medically necessary and appropriate; final claim processing is subject to contract terms.
- Contact Provider Services or Member Services with questions regarding specific member coverage.
Clinical Background and Evidence Summary
Eustachian tube dysfunction (ETD) occurs when the eustachian tube fails to open or close properly, impairing ventilation, clearance, and protection of the middle ear. Inflammatory or anatomic factors can produce obstructive ETD, which commonly presents with symptoms such as aural fullness, aural pressure, muffled hearing, tinnitus, and vertigo. Chronic obstructive ETD can lead to hearing loss, recurrent otitis media, tympanic membrane retraction or perforation, and cholesteatoma. Balloon dilation of the eustachian tube (BDET) is a minimally invasive transnasal endoscopic tuboplasty in which a saline-filled balloon catheter is introduced into the cartilaginous portion of the tube and inflated (typically for up to two minutes) to improve patency.
Definitions and Key Terms
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