Anthem Blue Cross Connecticut CG-SURG-117 Balloon Dilation of the Eustachian Tubes Form

This document addresses the use of balloon dilation of the Eustachian tubes (BDET), also known as balloon dilatation Eustachian tuboplasty. Balloon dilation of the Eustachian tubes is an endoscopic procedure that usually approaches the Eustachian tubes trans-nasally to expand and stretch the Eustachian tube using a balloon catheter. It is proposed to relieve chronic ear congestion and middle ear and mastoid infections.

Note: Please see the following related document(s):

• CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion
• CG-SURG-73 Balloon Sinus Ostial Dilation

Clinical Indications

Medically Necessary:

A single treatment of unilateral or bilateral balloon dilation of the Eustachian tubes via nasal endoscopy is considered medically necessary when all the following criteria are met for the ear(s) to be treated (A, B, C, D, and E):

1. The individual is 18 years of age or older; and
2. The individual’s history and physical exam include all the following (1, 2, 3, and 4):
   1. Eustachian tube dysfunction:
      1. Has been present for 3 months or more; and
      2. Persists despite medical therapy of any associated conditions (if present) such as allergic rhinitis, rhinosinusitis, or laryngopharyngeal reflux; and
   2. Otoscopic examination shows either of the following (i or ii):
      1. Persistent otitis media with effusion; or
      2. Tympanic membrane retraction; and
   3. Nasal endoscopic examination does not show physical obstruction of the Eustachian tube; and
   4. Either of the following (i or ii):
      1. Abnormal tympanogram tracings (Type B or C); or
      2. Symptoms consistent with baro-challenge induced Eustachian tube dysfunction (that is: recurrent aural fullness, popping, or pain that reproducibly occurs with changes in pressure); and
3. If history includes placement of tympanostomy tube(s), demonstrated improvement of obstructive Eustachian tube symptoms while the tube(s) were in place; and
4. No history of previous balloon dilation of the Eustachian tubes; and
5. No contraindication for balloon dilation, for example:
   1. Carotid abnormalities in the skull base; or
   2. Nasopharyngeal or skull base neoplasm; or
   3. Patulous Eustachian tube.

Not Medically Necessary:

Balloon dilation of the Eustachian tubes is considered not medically necessary when the criteria above are not met, and for all other indications.

Repeat balloon dilation of the Eustachian tube is not medically necessary for all indications.

Trans-tympanic balloon dilatation of the Eustachian tube is not medically necessary for all indications.