Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ear/Nose/Throat
Treatment: Surgical Services - Balloon dilatation Eustachian Tuboplasty
The insurer denied Balloon dilatation Eustachian Tuboplasty. 
The denial is overturned.

This patient is a female who has a perforated right tympanic membrane. She has a history of multiple sets of myringotomy tubes in the right ear and the tube fell out leaving a perforation that has not closed. The client also has hearing loss that is worsening along with associated ear pain. The patient has eustachian tube dysfunction and has experienced ear fullness, decreased hearing for many years, and has had multiple sets of tubes placed for this condition. She currently has perforation in her right eardrum which needs to be repaired. The physician notes the client is going to be having a tympanoplasty and myringotomy tubes cannot be placed when the surgery is being done to repair the eardrum. There is a computed tomography (CT) scan report of the sinuses showing sinus thickening and deviated septum with a spur but no other pathology.  A nasal endoscopy was done and a balloon sinuplasty was done. The exams showed a central tympanic perforation on the right and audiogram is present, showing right conductive hearing loss and tympanograms present. 

At issue is whether the Balloon dilatation eustachian tuboplasty is likely to be more beneficial than any standard treatment or treatments.

The health plan's determination regarding the proposed health service or treatment is overturned in whole.

The proposed health service or treatment Balloon dilatation Eustachian Tuboplasty is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has an extremely typical history of otitis and eustachian tube dysfunction issues. In spite of her treatments, her problem has recurred relative to her otitis which is caused by her eustachian tube dysfunction. This in turn has left her with a perforation of the eardrum.

The literature repeatedly supports the use of eustachian tube balloon dilation along with its efficacy and duration of improvement. There are  physicians who are routinely doing the eustachian tube dilation balloon in selected patients. It has been accepted by many physicians and is a standard of treatment for eustachian tube dysfunction as this client has.

Typical criteria for eustachian tube balloon dilation include exclusion of other causes of the eustachian tube problem which is satisfied by prior CT scan and multiple exams of the ears, audiogram and tympanogram demonstrating hearing loss which this client has had, and has a conductive hearing loss, appropriate age which this client satisfies, ear fullness and pressure which this client obviously satisfies by her need for myringotomies, endoscopic nasal exam which has been done, failure to respond to medical treatment which this client has satisfied by virtue of both the antibiotics and myringotomy, symptoms of obstructive eustachian tube dysfunction that improved with myringotomy tubes and the records indicate that this has occurred, and symptoms are continuous which is self-evident by the necessity of repeat myringotomy and tubes.

In summary, this client has eustachian tube dysfunction which required multiple myringotomy and tubes and resulted in a tympanic perforation and has been treated repeatedly. The literature and ENT (ear, nose, and throat) physicians consider this an efficacious procedure that is not investigational and is medically necessary and the current standard of care.

Therefore, the proposed health service or treatment Balloon dilatation Eustachian Tuboplasty is likely to be more beneficial than any standard treatment or treatments.