Prior authorization must include chart notes and abnormal tympanogram/tympanic membrane documentation; list covered codes

Prior authorization is required and must include chart notes plus documentation of an abnormal tympanogram or tympanic membrane abnormality. Covered procedure codes to reference on the authorization are CPT 69705, 69706, 69799 and HCPCS C9745.

• Submit chart notes with history documenting diagnosis and treatment of chronic ETD and otoscopy findings.
• Provide tympanogram showing Type B or C OR documentation of tympanic membrane abnormality.
• Reference covered codes: 69705, 69706, 69799, C9745 on the authorization request.

Document failure of medical management for co-occurring conditions when applicable

When applicable, document that the member failed to respond to medical management of co-occurring conditions before BDET is performed (examples provided by the policy).

• Allergic rhinitis/rhinosinusitis: trial of medical therapy including 4–6 weeks of a nasal steroid if indicated.
• Laryngopharyngeal reflux: trial of proton pump inhibitor or antacid therapy.

Information required with prior authorization: chart notes, history, treatment, and tympanic membrane/tympanogram documentation

Include chart notes with history documenting the diagnosis and prior treatments for chronic eustachian tube dysfunction, plus documentation of tympanic membrane abnormality and/or an abnormal tympanogram.

• History and treatment details for chronic ETD.
• Otoscopy findings showing tympanic membrane abnormality (retraction, effusion, perforation, or other abnormality).
• Tympanogram result demonstrating Type B or C when available.

Denial triggers: missing medical necessity elements or contraindications

Requests may be denied if all medical necessity criteria are not met; common denial triggers include insufficient symptom duration, patient age under 18, lack of abnormal tympanogram or tympanic membrane findings, prior BDET, or listed contraindications.

• Symptoms less than three months in duration.
• Patient is younger than 18 years.
• No documentation of abnormal tympanogram (Type B or C) or abnormal tympanic membrane on otoscopy.
• Prior balloon dilation of the eustachian tube (BDET) already performed.
• Presence of contraindications (e.g., extrinsic causes such as enlarged adenoids, history of nasopharyngeal radiation, craniofacial syndromes, nasopharyngeal mass, patulous ETD, chronic severe atelectatic ears).