Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Eustachian Tube Dysfunction. 

Treatment: Code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The insurer denied coverage for code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The denial is overturned. 

The patient is seeking coverage for 69705, an outpatient nasopharyngoscopy surgery with dilation of eustachian tube (procedure done in the ear). 

The patient presented for an evaluation related to chronic maxillary rhinosinusitis. The patient had right endoscopic sinus surgery and bilateral maxillary hardware removal. The patient had intermittent nasal obstruction that was worse on the right side and in the morning. The patient had been utilizing Flonase with some benefit. The patient continued to have popping of the ears on both sides. There was some right facial fullness sensation from time to time. The Sino-Nasal Outcome Test (SNOT-22) score was 24 which was a change from previous assessment of 36. The nasal symptom inventory score was 13 which was decreased from the previous 15. The patient had recurrent upper respiratory infections in the setting of having undergone elective orthognathic surgery. The patient underwent elective Le Fort I in segments, sagittal split osteotomies of the mandible, and extraction of wisdom teeth for mandibular hypoplasia and impacted wisdom teeth. The patient had multiple exacerbations. The patient had been on oral antibiotics approximately 6 times in the last 12 months. The patient was treated with mometasone furoate nasal spray. The patient had a sensation that the right ear was plugged/underwater. The symptoms fluctuated with sinonasal symptoms. The patient endorsed right forehead pressure during acute phase of sinus infections. The physical exam findings noted deviation of the septum to the left. There were no polyps, and the inferior turbinates were normal. A maxillofacial/head computed tomography (CT) noted bilateral ethmoid opacification. There was air-fluid level left sphenoid sinus.  The right frontal sinus was completely opacified. The left maxillary sinus had opacification.  

Based on current literature, the requested nasopharyngoscopy surgery with dilation of eustachian tube has approval based on current studies as being safe, effective, and beneficial for the patient's clinical presentation. The patient is a good candidate for the procedure given the failure of nonoperative treatment. Given the paucity of remaining available treatment options, the dilation of the eustachian tube is the best available treatment for the patient at the current time. Current literature did not identify adverse risks for increased over standard treatment/services. Long-term benefit has been established with the requested treatment. As such, the requested procedure is likely to be more beneficial than the remaining available standard treatments/procedures for this patient. As such, the denial of coverage for code 69705, an outpatient nasopharyngoscopy surgery with dilation of eustachian tube (procedure done in the ear) is overturned. 

In summary, the denial of code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure dine in the ear) and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.