CurrentuniverahealthcarePolicy 7.01.101

Balloon Dilation of the Eustachian Tube (BDET)

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Defines when BDET is considered medically appropriate or investigational for treatment of chronic obstructive Eustachian tube dysfunction (ETD) for Univera Healthcare members and what diagnostic and treatment history criteria must be met.

Policy Summary

Payeruniverahealthcare

PolicyBalloon Dilation of the Eustachian Tube (BDET)

Policy CodePolicy 7.01.101

Change TypeNo material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionObtain prior authorization confirming patient is ≥18, has no prior BDET in the same ear, and documentation shows symptomatic improvement after myringotomy/tympanostomy tube when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum age for coverage

>=3 monthsminimum symptom duration

no prior BDETprior BDET excludes coverage

investigational <18pediatrics stance

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CurrentuniverahealthcarePolicy 7.01.101

Balloon Dilation of the Eustachian Tube (BDET)

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Policy Summary

Payeruniverahealthcare

PolicyBalloon Dilation of the Eustachian Tube (BDET)

Policy CodePolicy 7.01.101

Change TypeNo material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum age for coverage

>=3 monthsminimum symptom duration

no prior BDETprior BDET excludes coverage

investigational <18pediatrics stance

FDA-approveddevice requirement

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

Medically necessary criteria

Covered when ALL of the following are met

Age: Patient is age 18 years or older>=18 years

Diagnostic evaluation: Comprehensive diagnostic evaluation documents abnormal tympanogram (Type B or C), abnormal tympanic membrane on exam (e.g., retracted membrane, effusion, or perforation), and other causes of aural fullness have been ruled out (e.g., temporomandibular joint disorders, extrinsic obstruction of the Eustachian tube, superior semicircular canal dehiscence, endolymphatic hydrops).

Symptoms of chronic obstructive ETD including aural fullness/pressure and hearing loss or otalgia, with symptoms lasting 3 months or longer that are continuous and not episodic (e.g., not limited to barochallenge).>=3 months continuous

Contraindications: Absence of any contraindication, including but not limited to patulous ETD and dehiscence of the carotid artery canal.

Prior procedure: No prior balloon dilation of the Eustachian tube (BDET) in the same ear for which the surgery is proposed.

Treatment history: Failure to respond to appropriate medical management of coexisting conditions (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux) when applicable; symptoms of obstructive ETD must have improved following myringotomy with tympanostomy tube placement (trial is not required for BDET).

Adult coverage rationale

Covered when ALL of the following are met:

Adult indication: Adult with chronic obstructive Eustachian tube dysfunction (ETD).

Supported by systematic reviews and randomized trials showing symptomatic and objective improvement (e.g., Poe et al RCT).

Failed medical management: Patient did not respond to appropriate medical management when applicable (examples include minimum intranasal steroid trial or course of oral steroid per cited trials).

Poe RCT required minimum steroid trials for enrollment; step-therapy expectations described in policy.

threshold":"","note":"Multiple studies used tympanogram normalization and ETDQ-7 as endpoints (Poe et al, meta-analyses).","children":[]}

Device and technique: Procedure performed transnasally using an FDA-approved balloon dilation device.

Transtympanic approach is considered investigational and not part of routine adult coverage.

Pediatric coverage stance

Not routinely covered / investigational for pediatrics unless criteria met in exceptional cases:

Pediatric evidence caution: Evidence in patients younger than 18 years is limited, heterogeneous, and of inadequate quality to recommend widespread use.

Existing pediatric studies are mainly retrospective cohorts and small series with mixed results; meta-analyses note limitations.

Consideration: BDET may be considered after failed standard pediatric treatments (e.g., tympanostomy tube placement, adenoidectomy) when clinicians document rationale and obtain informed consent discussing limited evidence and alternative options.

Some pediatric series and meta-analyses report improvements but recommend further RCTs before routine use.

Medical necessity criteria (summarized)

Covered when ALL of the following are met (as supported by AAO-HNS consensus, NICE guidance, FDA indications, and cited studies):

Chronicity: Symptoms of obstructive Eustachian tube dysfunction persisting for 3 months or longer in adults.>= 3 months (adults)

AAO-HNS consensus and policy text specify 3 months for adults.

Refractory to medical therapy: Objective signs of persistent obstructive ETD or chronic otitis media with effusion that are refractory to medical treatment and prior standard surgical interventions when applicable.failed medical therapy and, when applicable, failed at least one surgical intervention

NICE guidance and FDA expanded indication language reference refractory disease and prior interventions.

Age/Device labeling: Patient age must be consistent with the FDA clearance/labeling for the balloon dilation system being used (some devices cleared for 18+, one expanded indication to ages 8-17 for a specific system).

Investigational: Transtympanic BDET

Not covered / considered investigational when:

Transtympanic approach: Use of transtympanic BDET (transtympanic dilation of the proximal cartilaginous Eustachian tube) due to insufficient peer-reviewed evidence to support safety and efficacy.N/A

Systematic review, small case series, and cadaver studies cited; further study warranted.

BDET is considered investigational for all other indications not explicitly covered by the policy. Examples include use as a repeat procedure, when performed concurrent with tympanoplasty or other middle ear surgery (e.g., mastoidectomy), and for patients presenting with aural fullness despite a normal ear examination and tympanogram.

The policy designates certain situations as investigational, including the transtympanic approach, patients aged 17 years and younger, and ETD attributable to extrinsic causes of obstruction (for example, enlarged adenoids, prior nasopharyngeal radiation, craniofacial syndromes, or nasopharyngeal/skull base neoplasms).

The transtympanic technique for BDET is explicitly described as having insufficient peer-reviewed evidence to establish safety and efficacy. Available reports include small case series and cadaver studies; the policy concludes that further study is warranted and therefore classifies transtympanic BDET as investigational.

Coverage of BDET services is contract dependent. If a member's product does not cover a service, the medical policy criteria do not apply; when a product does cover the service, the medical policy criteria should be used to adjudicate benefit eligibility.

Any indication that does not meet the policy's specified medical necessity criteria is considered investigational / not medically necessary. This includes repeat procedures, concurrent middle ear surgery, transtympanic approaches, procedures for patients 17 years or younger, and procedures for aural fullness with otherwise normal exam and tympanometry.

If symptoms persist despite a functioning myringotomy or tympanostomy tube, the policy advises that this finding suggests an alternative diagnosis (for example, patulous ETD) rather than obstructive ETD and would not support BDET.

The literature and expert consensus identified in the policy note that there is little evidence

Coding and Device Requirements

Device requirementmixed

FDA device requirement

BDET can only be performed with a balloon dilation device/system that is approved by the U.S. FDA

CPT CodesCPT

31231	Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure).
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.
69799	Unlisted procedure, middle ear.
92511	Nasopharyngoscopy with endoscope (separate procedure).

HCPCS CodesHCPCS

No codes listed

ICD-10 CodesICD-10

H65.00-H65.93	Nonsuppurative otitis media (code range)
H66.001-H66.93	Suppurative and unspecified otitis media (code range)
H67.1-H67.9	Otitis media in diseases classified elsewhere (code range)
H68.001-H68.029	Eustachian salpingitis and obstruction (code range)
H69.80-H69.93	Other specified and unspecified disorders of Eustachian tube (code range)
H71.00-H71.93	Cholesteatoma of middle ear (code range)
H72.00-H72.93	Perforation of tympanic membrane (code range)
H81.01-H81.09	Meniere's disease (code range)
J30.0-J30.9	Vasomotor and allergic rhinitis (code range)
J31.0-J31.2	Chronic rhinitis, nasopharyngitis and pharyngitis (code range)

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Prior Authorization, Documentation, and Denial Risks

Prior Authorization
Prior authorization: confirm age, prior BDET, and tympanostomy response
Submit prior authorization confirming patient is age 18 years or older, there is no prior BDET in the same ear proposed for surgery, and that symptoms improved following myringotomy with tympanostomy tube placement (a tympanostomy tube trial is not required for BDET).
Age must be ≥18 years.
No prior BDET performed in the same ear.
Document improvement after myringotomy/tympanostomy tube placement (trial not required).

Prior Authorization
Prior authorization: FDA‑approved device and patient selection
For BDET requests, include documentation that the procedure will use an FDA‑approved balloon dilation device/system and that patient selection meets diagnostic criteria (failed medical management when applicable; abnormal tympanometry and symptomatic dysfunction for adults).
Device used must be FDA‑approved for the intended age/indication.

Background and Evidence Summary

Eustachian tube dysfunction (ETD) produces symptoms such as aural fullness or pressure, hearing loss, or otalgia and is associated with objective middle-ear findings. Balloon dilation of the Eustachian tube (BDET) is an interventional procedure intended to treat chronic obstructive ETD when diagnostic testing (e.g., abnormal tympanogram or tympanic membrane exam) and prior management meet the policy's eligibility criteria.

Definitions and Diagnostic Terms

Abnormal tympanogram — Type B or Type C tympanogram documented

DefinitionType B or Type C tympanogram documented on diagnostic evaluation.

Evidence sourceListed as required objective finding in comprehensive diagnostic evaluation for BDET eligibility.

Clinical implicationSupports diagnosis of middle-ear effusion or negative middle-ear pressure consistent with obstructive ETD.

Abnormal tympanic membrane exam — retracted membrane, effusion, or perforation

DefinitionFindings such as retracted membrane, effusion, or perforation on otoscopic examination.

RequirementDocumented abnormal tympanic membrane exam is part of the comprehensive diagnostic evaluation for BDET eligibility.

Policy Summary

Payeruniverahealthcare

PolicyBalloon Dilation of the Eustachian Tube (BDET)

Policy CodePolicy 7.01.101

Change TypeNo material changes

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

SourceLink

On This Page

age per device IF device-specific clearance is relied upon

Policy references device regulatory milestones including Acclarent AERA expansion and other device clearances.

Support indication with abnormal tympanogram and symptomatic dysfunction; document prior medical management failures when applicable.

Prior Authorization
Prior authorization: include applicable CPT/diagnosis codes
When requesting authorization, reference the applicable CPT codes from the policy (e.g., 69705, 69706) since prior authorization may be required for nasopharyngoscopy with BDET and related procedure codes; use the policy coding list when submitting the request.
Common codes: 69705 (unilateral), 69706 (bilateral); also 31231, 92511, and 69799 as listed in policy.
Include relevant ICD‑10 diagnosis codes supporting ETD from the policy's code list.

Prior Authorization
Prior authorization: check product‑specific coverage and contract
Verify member product coverage before authorization: if the member's product covers BDET, the medical policy criteria apply; prior authorization requirements and benefit applicability vary by product and contract.
Coverage and authorization requirements depend on whether the service is covered by the member's commercial, Essential Plan, Child Health Plus, Medicaid, or Medicare product.

Documentation Required
Document prior treatment failures for coexisting conditions
Document treatment history showing failure to respond to appropriate medical management of coexisting conditions when applicable (e.g., allergic rhinitis, rhinosinusitis, laryngopharyngeal reflux).
Report specific medical therapies tried and the clinical response.
Note that tympanostomy tube response should be documented (improvement required).

Step Therapy
Step therapy: document failed intranasal/oral steroid trials when applicable
Expect to document failed appropriate medical management before BDET in adults when applicable (examples cited include a trial of intranasal steroid spray or a course of oral steroid per clinical trials).
Poe RCT required ≥4 weeks continuous intranasal steroid use or a completed course of oral steroid within 90 days for enrollment.
Document specific medication trials and durations used.

Note
Pediatric use: typically second‑line and evidence limited
For pediatric cases, note that BDET was often used as a second‑line treatment in published pediatric studies and guidance emphasizes use for chronic, refractory cases; quality of evidence in patients <18 is limited and heterogeneous.
Pediatric literature mostly comprised small retrospective series where BDET followed standard treatments such as tympanostomy tubes or adenoidectomy.
AAO‑HNS and NICE statements highlight limited evidence and recommend caution for routine pediatric use.

Step Therapy
Step therapy: governed by product and local rules (no CMS mandate)
Be aware that step‑therapy requirements are governed by the member's product and local rules; there is no CMS policy mandating step‑therapy flows for BDET.
Local product rules determine whether documented prior medical therapy is required before authorization.
No national CMS coverage policy exists to impose step‑therapy mandates.

Documentation Required
Diagnostic requirement: abnormal tympanogram and TM exam
Include diagnostic documentation showing an abnormal tympanogram (Type B or C) and an abnormal tympanic membrane on examination (e.g., retraction, effusion, or perforation) as part of the preauthorization package.
Specify tympanogram type (B or C) and otoscopic findings.
Document exclusion of other causes of aural fullness (e.g., TMJ disorder, extrinsic ET obstruction).

Documentation Required
Symptom documentation: obstructive ETD symptoms ≥3 months
Document symptoms consistent with obstructive ETD—aural fullness/pressure, hearing loss or otalgia—and confirm symptoms have been present continuously for 3 months or longer in adults.
Symptoms should be continuous and not limited to isolated barochallenge events.
Record duration explicitly (≥3 months for adults).

Documentation Required
Required diagnostic documentation: H&P, otoscopy, nasal endoscopy, audiometry, tympanometry
Provide comprehensive diagnostic records including history and physical, otoscopy, nasal endoscopy, audiometry, and tympanometry when submitting for authorization or claims review.
Include documentation of any concurrent procedures (e.g., myringotomy/tympanostomy) performed at the time of BDET.
Attach audiogram and nasal endoscopy findings to support selection.

Documentation Required
Chronicity and prior treatment: document ≥3 months, prior therapies, objective signs, and device used
Record chronicity (≥3 months in adults), prior medical and surgical treatments attempted and failed, objective signs of persistent obstructive ETD or chronic otitis media with effusion, and the specific device used with age indication tied to FDA clearance.
Document prior surgical interventions (e.g., tympanostomy tubes, adenoidectomy) and outcomes.
Specify the balloon device and the FDA‑cleared age indication being relied upon.

Note
Benefit applicability: policy criteria apply when product covers service
When a member product covers BDET, ensure submitted documentation meets the medical policy criteria; the same policy criteria apply across covered product types (commercial, Essential Plan, Child Health Plus, Medicaid, Medicare) unless product rules differ.
If the product covers the service, apply the policy's medical necessity criteria in the authorization review.
If a product does not cover the service, medical policy criteria do not apply.

Denial Risk
Denial risk: prior BDET in same ear or patient ≤17 years
Anticipate denials if the patient has a history of prior BDET in the same ear or if the patient is 17 years of age or younger; include documentation to rule out these exclusionary conditions.
Prior BDET in the same ear is an exclusion for coverage.
Patients aged ≤17 are categorized as investigational and may be denied.

Denial Risk
Denial risk: investigational indications (transtympanic, pediatric, extrinsic obstruction)
Do not request coverage for transtympanic BDET, patients age 17 years and younger, or ETD caused by extrinsic obstruction (e.g., enlarged adenoids, prior nasopharyngeal radiation, craniofacial syndromes, neoplasm) — these indications are considered investigational and will lead to denial.
Transtympanic approach is explicitly investigational.
Extrinsic causes of ETD and patients ≤17 years are noncovered indications.

Denial Risk
Denial risk: limited effectiveness evidence and unclear benefit of repeat procedures
Recognize that BDET is not effective for all patients and the literature provides limited evidence for repeat procedures; absence of documented chronic refractory OETD and prior treatment failures may result in denial.
AAO‑HNS and NICE note limited evidence on benefit of repeat BDET and that the procedure is indicated only for chronic ETD refractory to medical treatment.
Document objective and symptomatic indications to support expected benefit.

Denial Risk
Denial risk: lack of contract coverage (product dependent)
Confirm contract-level coverage before submission: services are contract dependent, and if a member's product does not cover BDET the medical policy criteria do not apply and the claim/authorization may be denied for lack of coverage.
Verify coverage under the specific commercial, Medicaid, or Medicare product prior to requesting authorization.
If the product excludes the service, do not rely on the medical policy to establish coverage.

DifferentialAn abnormal TM exam helps distinguish obstructive ETD from non-otologic causes of aural fullness.

Obstructive ETD — decreased patency due to functional or anatomical obstruction

DefinitionDecreased patency of the Eustachian tube due to a functional or anatomical obstruction.

ExamplesObstructions may be functional valve failure or anatomic narrowing of the cartilaginous ET.

Relevance to BDETObstructive ETD is the target condition for transnasal BDET per policy criteria.

Patulous ETD — pathologically patent Eustachian tube causing autophony

DefinitionPathologically patent Eustachian tube causing autophony and audible respirations.

Clinical notePatulous ETD is a contraindication to BDET and should be identified during evaluation.

Diagnostic clueSymptoms include autophony of voice and awareness of breathing; exam may show tympanic membrane movement with respiration.

Baro-challenge-induced ETD — failure of ET to open during ambient pressure changes

DefinitionFailure of the Eustachian tube to open during ambient pressure changes despite normal function in normobaric situations.

Clinical contextMay present with symptoms related to barometric pressure changes; policy distinguishes baro-challenge-induced ETD from chronic obstructive ETD.

ImplicationBaro-challenge ETD alone does not meet chronicity criteria for BDET unless other objective and chronic findings are present.

obstructive Eustachian tube dysfunction — OETD abbreviation and mapping

Preferred termObstructive Eustachian tube dysfunction (OETD)

SynonymOETD is used interchangeably with obstructive ETD in consensus statements and trials.

Target for BDETOETD is the primary condition addressed by transnasal BDET per AAO-HNS and NICE guidance.

transtympanic BDET — definition of transtympanic approach and rationale for investigational status

DefinitionTranstympanic BDET attempts dilation of the proximal (tympanic-end) cartilaginous Eustachian tube via a transtympanic route.

Evidence statusInsufficient peer‑reviewed evidence to support safety and efficacy; systematic reviews and small case series/cadaver studies cited.

Policy stanceTranstympanic approach is considered investigational and not supported for routine use pending further study.

Obstructive or dilatory Eustachian tube dysfunction — referenced in consensus statements and trials

Condition targetedObstructive or dilatory Eustachian tube dysfunction is the target condition cited in consensus statements and clinical trials.

Guideline referencesAAO‑HNS consensus statement and NICE guidance reference OETD as the population for BDET; randomized trials and systematic reviews cited.

Clinical criteriaTrials and statements emphasize objective findings (tympanometry, otoscopy) and chronicity/refractoriness to medical therapy as diagnostic requirements.