Point32 Balloon Dilation of the Eustachian Tube Form

Eustachian tube (ET) dysfunction

Eustachian tube (ET) dysfunction occurs when the functional valve of the eustachian tube fails to open and/or close properly. This failure is frequently due to inflammation and can cause symptoms such as muffled hearing, ear fullness, tinnitus, and vertigo. Chronic dysfunction can lead to hearing loss, otitis media, tympanic membrane perforation, and cholesteatomas. Balloon dilation of the eustachian tube (BDET) is a procedure intended to improve the patency by inflating a balloon in the cartilaginous part of the ET to cause local dilation.

Clinical Guideline Coverage Criteria

Balloon dilation of the eustachian tube (BDET) may be considered medically necessary for adults (18 years and older) with chronic eustachian tube dysfunction refractory to medical treatment when ALL of the following criteria are met:

• The Member has the following:
  1. Chronic signs and symptoms of eustachian tube (ET) obstruction such as:
     • Hearing loss or aural fullness for greater than 3 months duration and other causes such as temporomandibular joint disorders, extrinsic obstruction of the ET, superior semicircular canal dehiscence, and endolymphatic hydrops have been ruled out OR
     • There is a history of negative pressure in the middle ear, middle ear effusion for greater than or 3 months duration; AND
  2. There is failure to respond to appropriate medical management of co-occurring conditions such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux, including 4-6 weeks of a nasal steroid spray, if indicated
• AND
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Balloon Dilation of the Eustachian Tube

1o There are no contraindications to BDET

Limitations

The Plan will not cover balloon dilation of the eustachian tube (BDET) for the following indications:

• Members aged 17 and younger
• Repeat BDET
• BDET for patulous eustachian tube dysfunction

Codes