Anthem Blue Cross Connecticut CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion Form

This document addresses myringotomy and tympanostomy tube insertion, which are procedures used to decompress and ventilate the middle ear when fluid builds up due to infection, trauma, or other conditions. Tympanostomy tubes are also known by other terms, including grommet, T-tube, ear tube, pressure equalization (PE) tube, vent, or myringotomy tube.

Clinical Indications

Medically Necessary:

The use of combined myringotomy and tympanostomy tube insertion is considered medically necessary for individuals who meet any of the following criteria:

1. Children or adults with recurrent acute otitis media (AOM) (more than 3 episodes in 6 months or more than 4 episodes in 12 months) with or without otitis media with effusion (OME) who have middle ear effusion at the time of assessment for tube candidacy; or
2. Children with unilateral or bilateral OME for greater than or equal to 3 months with hearing loss greater than 20 dB in one or both ears; or
3. Children with recurrent AOM or OME of any duration when the child is at risk for speech, language, or learning delay or disorder from OM based on baseline sensory, physical, cognitive, or behavioral factors including, but not limited to, the following:
   1. Confirmed speech or language delay or disorder.
   2. Autism spectrum disorder or other pervasive developmental disorder.
   3. Syndromes (for instance, Down) or craniofacial disorders that include cognitive, speech, or language delays.
   4. Intellectual disability, learning disorder, or attention-deficit/hyperactivity disorder.
   5. Blindness or uncorrectable visual impairment.
   6. Cleft palate, with or without associated syndrome; or
4. Children or adults with structural damage to the tympanic membrane (TM) or middle ear, such as cholesteatoma, chronic retraction of tympanic membrane or pars flaccida; or
5. Children or adults with barotitis (barotrauma); or
6. Children or adults with autophony due to patulous eustachian tube; or
7. Children or adults with middle ear dysfunction due to head and neck radiation or skull base surgery; or
8. Children or adults with a severe complication of acute otitis media including, but not limited to: meningitis, intracranial abscess, mastoiditis, or facial nerve paralysis; or
9. Adults with OME greater than 3 months and continued symptoms of aural pressure or hearing loss; or
10. Children or adults with persistent AOM despite at least 2 different courses of recommended empiric antibiotic therapy.

The use of myringotomy as a stand-alone procedure is considered medically necessary for individuals who meet one or more of the following criteria:

1. Neonates with otitis media who are either:
   1. 16 or fewer weeks of age for full term infants; or
   2. Premature infant whose adjusted age (actual age – # weeks premature) is less than 16 weeks; or
2. Individual with acute otitis media and an immunocompromising condition such as cancer chemotherapy or use of anti-rejection medications following a transplant; or
3. Individual who meets criteria for tympanostomy and tube insertion but for whom tube insertion is not feasible due to the degree of ear inflammation.

Not Medically Necessary:

The use of myringotomy alone is considered not medically necessary when the criteria above have not been met and for all other indications.

The use of combined myringotomy and tympanostomy tube insertion is considered not medically necessary when the criteria above have not been met and for all other indications.