ModifiedPremera BluecrossPolicy 7.01.606

Balloon Dilation of the Eustachian Tube

Defines medical necessity, contraindications, documentation, and coding for balloon dilation of the eustachian tube for Premera Bluecross members; applies to providers performing BDET and to coverage review.

Policy Summary

PayerPremera Bluecross

PolicyBalloon Dilation of the Eustachian Tube

Policy CodePolicy 7.01.606

Change TypeAge and symptom-duration criteria revisedexclusions added

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization documenting age ≥8 years, symptom duration ≥3 months, objective tympanogram (Type B or C), and failure of indicated medical therapy when required.

SourceLink

POLICY UPDATE CHANGES

FDA expanded indication for the Acclarent AERA system to include pediatric patients aged 8 to 17 years with persistent obstructive ETD refractory to medical management.

The minimum age for coverage was changed from 'aged 22 years or older' to 'aged 8 years or older'.

Required symptom duration for coverage was changed from 'symptoms for 12 months or longer' to 'symptoms for 3 months or longer'.

Added list of conditions for which BDET is considered not medically necessary.

Stated that BDET in individuals younger than 8 years is investigational.

≥8Minimum age for coverage

≥3 moMinimum symptom duration

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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

Initial therapy (Medical necessity)

Covered when ALL of the following are met

Age: Individual is aged 8 years or older>= 8 years

Acclarent AERA labeled for age >=8

Symptoms duration and type: Symptoms of obstructive ETD (aural fullness, aural pressure, otalgia and/or hearing loss) are present for 3 months or longer in one or both ears and significantly affect quality of life or functional health status; symptoms are continuous rather than episodic>= 3 months

Symptoms should be continuous (not only with barochallenge)

No prior BDET: A previous BDET procedure has not been performednone

Diagnostic assessment: Comprehensive diagnostic assessment performed (may include tympanometry if TM intact, nasal endoscopy, and comprehensive audiometry) with abnormal tympanogram (Type B or C) and abnormal tympanic membrane on otoscopy (retraction, effusion, perforation, or other abnormality)Type B or C tympanogram

Reversibility of ETD must be demonstrated (e.g., Valsalva resulting in temporary Type A or lateral TM movement on otoscopy)

Failed medical management of co-occurring conditions: If applicable, failure to respond to appropriate medical management of potential co-occurring conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux); when indicated, includes a trial of intranasal corticosteroid therapy for 4-6 weeks or PPI/antacid for reflux4-6 weeks when indicated

Other causes of aural fullness must be ruled out

Other causes excluded: Extrinsic causes of ET obstruction and other causes of aural fullness have been ruled out (e.g., adenoid tissue or nasopharyngeal mass, endolymphatic hydrops, superior semicircular canal dehiscence, temporomandibular joint disorders)none

History of tympanostomy tube response when applicable: If there is a history of tympanostomy tube placement, symptoms of obstructive ETD improved while tubes were patentif applicable

Supports reversible ETD

Initial coverage criteria

Covered when ALL of the following are met

Age: Individual is aged 8 years or older.>=8 years

Policy updated from prior age threshold; Acclarent AERA cleared for pediatric 8–17 years

Symptom duration: Obstructive ETD symptoms present for 3 months or longer that significantly affect quality of life or functional health status.>=3 months

Replaces prior 12-month requirement

Objective evidence of middle ear dysfunction is present (e.g., abnormal tympanometry Type B or C, retraction, effusion, or cholesteatoma)objective findings required

Includes tympanometry and audiometry

The policy lists explicit contraindications and exclusions for balloon dilation of the eustachian tube (BDET). Contraindicated conditions include patulous ETD (where the eustachian tube remains open), and extrinsic reversible or irreversible causes of ETD such as craniofacial syndromes (including cleft palate spectrum), neoplasms causing extrinsic obstruction, history of radiation to the nasopharynx, enlarged adenoids, or nasopharyngeal mass. Additional exclusions include neuromuscular disorders causing ineffective ET opening, active systemic mucosal or autoimmune inflammatory disease affecting the nasopharynx/eustachian tube, individuals with aural fullness but a normal exam and tympanogram, chronic severe atelectatic ears (retracted tympanic membrane), dehiscent carotid artery without appropriate device safeguards, active acute infection of the nasopharynx or middle ear, coagulopathy/bleeding disorders, and trisomy 21.

Per society guidance and the policy, BDET is contraindicated for individuals diagnosed with patulous ETD. The American Academy of Otolaryngology–Head and Neck Surgery (2019) consensus explicitly states that BDET should not be offered to patients with patulous ETD and emphasizes comprehensive assessment (otoscopy, audiometry, nasal endoscopy) to identify other treatable causes before proceeding with dilation. The policy reflects this by adding an explicit list of conditions considered not medically necessary for BDET and by flagging patulous ETD as a contraindication.

The policy states that BDET is considered not medically necessary for individuals with any of the listed contraindications (see exclusions). Examples include patulous ETD, extrinsic causes such as neoplasms or prior nasopharyngeal radiation, active infection, coagulopathy, chronic severe atelectasis, and trisomy 21 among others; procedures for members with these conditions may be denied as not medically necessary.

The policy contains an investigational statement specifying that BDET in individuals younger than 8 years of age is considered investigational. This mirrors the document’s updated age-based coverage stance and is explicitly noted under the policy’s not medically necessary / investigational language.

The policy clearly states that treatment with BDET is not medically necessary when the stated coverage criteria are not met. Additionally, it explicitly classifies BDET as investigational for individuals aged < 8 years, and such procedures are not covered under the policy.

Coding and Regulatory Identifiers

Covered CPT CodesCPTCovered

69705	Nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); unilateral.
69706	Nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral.

Historical coding changesHCPCS

C9745

HCPCS code previously added then removed (historical note)

FDA device 510(k) numbers referencedmixed

K171761	Acclarent Aera — 510(k) no. listed
K230742	Acclarent Aera — 510(k) no. listed (pediatric expansion)
K163509	Xpress ENT Dilation System — 510(k) no. listed
K210841	Nuvent Eustachian Tube Dilation Balloon — 510(k) no. listed
K220027	Audion ET Dilation System — 510(k) no. listed
K230065	Vensure Balloon Dilation System — 510(k) no. listed

inv-11: Tympanogram abnormality — required abnormal tympanogram types supporting eligibility (Type B or Type C)

Required tympanogram typesType B or Type C tympanogram required as objective evidence of middle ear dysfunction

Role in eligibilityAbnormal tympanogram must be documented as part of a comprehensive diagnostic assessment (tympanometry if TM intact)

ExamplesType B: flat trace consistent with middle ear pathology; Type C: negatively shifted peak indicating negative middle ear pressure consistent with ETD

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization: CPT Codes

Prior authorization is required and must document that medical necessity criteria are met for the following CPT codes.

69705 — Nasopharyngoscopy, surgical, with dilation of eustachian tube; unilateral
69706 — Nasopharyngoscopy, surgical, with dilation of eustachian tube; bilateral

Prior Authorization

Prior Authorization Requirements

Prior authorization requests must confirm that the individual meets age and symptom-duration requirements and that conservative management and diagnostic evaluation have been completed as described in the policy.

Age ≥ 8 years for procedure (note: FDA expanded indication for Acclarent AERA to ages 8–17)
Symptoms consistent with obstructive Eustachian tube dysfunction present and continuous rather than episodic
Symptoms present for ≥ 3 months (or consistent with policy language)
No prior balloon dilation of the eustachian tube documented

Background and Evidence Summary

Eustachian tube dysfunction (ETD) is a disorder in which the eustachian tube fails to open and close appropriately, leading to symptoms such as aural fullness, aural pressure, otalgia, and hearing changes. These symptoms, when persistent, can impair quality of life and may be associated with middle ear pathology (effusion, retraction) detectable on otoscopy and tympanometry. Balloon dilation of the eustachian tube (BDET) is a minimally invasive transnasal endoscopic tuboplasty intended to improve patency of the cartilaginous portion of the eustachian tube; society guidance recommends comprehensive assessment (otoscopy, audiometry, and nasal endoscopy) and exclusion of contraindications (for example, patulous ETD) before offering BDET.

Definitions and Key Terms

inv-22: Type A tympanogram — normal middle ear function

DefinitionType A tympanogram: normal middle ear system, free of fluid or physiological anomalies (pyramid/teepee shape)

Clinical implicationRepresents normal middle ear function and is not supportive of ETD diagnosis for BDET candidacy

Use in assessmentTympanogram Type A may be observed after reversible maneuvers (e.g., Valsalva) demonstrating transient improvement

inv-23: Type B tympanogram — flat trace consistent with middle ear pathology

DefinitionType B tympanogram: flat line on the graph consistent with middle ear pathology such as fluid, infection, or perforation

Clinical implicationIndicates middle ear pathology and fulfills the objective tympanometry requirement for BDET candidacy when present

Policy Summary

PayerPremera Bluecross

PolicyBalloon Dilation of the Eustachian Tube

Policy CodePolicy 7.01.606

Change TypeAge and symptom-duration criteria revisedexclusions added

Effective DateMay 1, 2026

Next Review Date

Key ActionObtain prior authorization documenting age ≥8 years, symptom duration ≥3 months, objective tympanogram (Type B or C), and failure of indicated medical therapy when required.

SourceLink

On This Page

Documentation Required

Required Medical Therapy Trials

Prior authorization must include documentation that appropriate medical therapy trials were attempted and failed for co-occurring conditions when clinically indicated.

Trial of intranasal corticosteroid therapy for 4–6 weeks when indicated (e.g., allergic rhinitis, rhinosinusitis)
For laryngopharyngeal reflux, trial of proton pump inhibitor or antacid therapy as clinically indicated
Other condition-specific medical management attempted and failed as appropriate

Documentation Required

Required Documentation for Medical Necessity Review

Provide complete clinical documentation to support medical necessity; missing elements may trigger denial.

Office visit notes with relevant history and physical exam
Age documented (≥ 8 years)
Symptom description: aural fullness/pressure, continuous symptoms, symptom duration ≥ 3 months
Tympanometry report showing abnormal tympanogram (type B or C) and documentation of tympanic membrane abnormality
Documentation that other causes of aural fullness have been ruled out (e.g., endolymphatic hydrops, extrinsic obstruction, SSC dehiscence, TMJ disorders)
If prior tympanostomy tubes placed, documentation that symptoms improved while tubes were patent
Documentation that Eustachian tube dysfunction is reversible (e.g., Valsalva produces temporary improvement or change to Type A tympanogram; visualization of lateral tympanic membrane movement)
If applicable, comprehensive diagnostic assessment including nasopharyngoscopy and audiometry

Documentation Required

Required Clinical Documentation

Required clinical assessment elements that must be included in the prior authorization submission to demonstrate objective dysfunction and appropriate workup.

History and physical exam consistent with obstructive ETD
Tympanometry (include report) if tympanic membrane intact
Nasopharyngoscopy findings (when performed)
Comprehensive audiometry when clinically indicated
Objective evidence of middle ear dysfunction (e.g., abnormal tympanometry, retraction, effusion, cholesteatoma)

Denial Risk

Contraindications That Trigger Noncoverage

Contraindications and specific situations that will generally lead to noncoverage or denial of BDET.

Patulous ETD (persistent open eustachian tube) — diagnosis suggested by autophony, audible respiration, pulsatile tinnitus
Extrinsic reversible or irreversible causes of ETD: craniofacial syndromes (including cleft palate spectrum), neoplasms causing obstruction, history of nasopharyngeal radiation, enlarged adenoids, nasopharyngeal mass
Neuromuscular disorders causing ineffective ET opening, systemic mucosal/autoimmune inflammatory disease affecting nasopharynx (active disease)
Individuals with aural fullness but normal exam and tympanogram
Chronic and severe atelectatic ears (retracted tympanic membrane)
Dehiscent carotid artery on imaging without appropriate device safeguards
Active acute infection of nasopharynx or middle ear
Coagulopathy or bleeding disorders
Trisomy 21

Denial Risk

Denial Triggers

Common denial triggers—cases where the request should be denied if criteria are not met or documentation is insufficient.

Individual younger than 8 years of age (BDET in <8 is investigational)
Lack of objective evidence of middle ear dysfunction (normal tympanogram with normal exam)
Symptoms duration or pattern not meeting policy (episodic symptoms or <3 months without meeting other criteria)
No documentation of failure of appropriate medical management for co-occurring conditions when indicated
Missing tympanometry report, nasopharyngoscopy, or other required diagnostic assessments
Presence of any contraindication listed in the policy

inv-25: Balloon dilation of the Eustachian tube — brief procedure definition

ProcedureMinimally invasive transnasal endoscopic tuboplasty using a saline-filled balloon catheter introduced into the cartilaginous Eustachian tube to dilate and improve patency

Technique detailsBalloon is inflated and pressure maintained (approximately two minutes or less) then emptied and removed; usually performed under general anesthesia

Context of useCan be performed as a standalone procedure or concurrently with other ENT procedures (e.g., adenoidectomy, myringotomy with tympanostomy tube)

inv-26: Obstructive Eustachian Tube Dysfunction (ETD) — symptom-duration definition (>=3 months) and assessment requirements

Symptom-duration thresholdSymptoms of obstructive ETD (aural fullness, aural pressure, otalgia, and/or hearing loss) present for 3 months or longer (continuous rather than episodic)

Required assessmentComprehensive diagnostic assessment including otoscopy, tympanometry (if TM intact), nasopharyngoscopy, and comprehensive audiometry

Exclusion requirementPatulous ETD must be excluded; other treatable causes (allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux) should be addressed prior to BDET

Response to medical managementIf applicable, failure to respond to appropriate medical management (e.g., 4–6 weeks intranasal corticosteroid when indicated) should be documented