Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Eustachian Tube Dysfunction

Treatment: coverage for balloon dilation of the eustachian tube

The insurer denied coverage for balloon dilation of the eustachian tube.

The denial is overturned.

This female patient has more than 3 months of eustachian tube dysfunction in both ears. The patient has experienced cracking and popping in the ears and has bilateral tinnitus and severe otalgia. Additionally, she complains of neck pain and vertigo. She has had audiometric assessment including tympanometry and comprehensive audiometry along with history and physical exams. She has had an x-ray of the neck and computed tomography (CT) of the sinuses. Her medications include Flonase, Xyzal, mometasone, Singulair and anti-inflammatories with minimal relief. Records additionally note that her medical doctor has tried her on a course of prednisone which gave her some help but then her symptoms returned. She had a CT scan done which showed no significant findings with normal middle ear. There are multiple office notes describing her persistence of eustachian tube dysfunction symptoms along with repeated medications including steroids, nasal steroids, and allergy medicines along with meclizine and anti-inflammatories. She did have myringotomy tubes. Included in the records are multiple studies and a discussion of the benefits of eustachian tube balloon dilation all presumably provided by the treating physicians. There are further records from her physician noting her eustachian tube dysfunction is fluctuating and an audiogram that noted flat tympanograms. The facility records include an operative note in which a eustachian tube dilation was done bilaterally and myringotomy and tubes were placed bilaterally.

The records indicate this patient has a substantial history of eustachian tube dysfunction. Repeat visits with her physicians document eustachian tube dysfunction. They also document the sequela of the dysfunction with complaints of vertigo, popping, otalgia and tinnitus. She has been treated with multiple and many medications including oral steroids, antihistamines, nasal steroids, Xyzal, meclizine, Singulair, and anti-inflammatories. This is a substantial list of medications, and she has not substantially improved with these medications. Additionally, she has had a CT scan of the sinuses and the ears and there is no pathology in the ears, and she had what was described as chronic sinusitis. She has an audiogram which showed flat tympanograms according to the records. Her symptoms and persistence of her complaints necessitated that she needed to have a myringotomy and tubes along with her balloon dilation of the eustachian tubes. Her physician described her as a good candidate for the balloon dilation and her history and the records appear to validate that.

There are multiple studies showing the efficacy safety and durability of eustachian tube dilation. The scientific evidence in peer-reviewed literature does appear to support a result of improvement in health outcomes. It does appear that eustachian tube balloon dilation has approval from appropriate regulatory bodies. This patient is a good candidate for the procedure of eustachian tube dilation as indicated above due to her persistence of symptoms in spite of multiple medications and a medical work-up. The procedure does appear to be the best available treatment for this patient at this time.

The requested service appears to be more beneficial than any other standard treatment. In particular, there are limited options for this patient, which is consistent with the procedure being medically necessary, appropriate, and indicated. The literature does not appear to note increased adverse risks or standard treatment.

The carrier's denial of the balloon dilation of eustachian tube should be overturned.