Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ears/Nose/Throat. 

Treatment: Balloon dilation of Eustachian tube, code 69799.

The insurer denied coverage for balloon dilation of Eustachian tube, code 69799.

The denial is overturned. 

This is a female patient who has had chronic ear disease including chronic otitis media, cholesteatoma and conductive hearing loss.  The patient has had mastoidectomy with an ossicular implant and grafting.  Due to the patient's Eustachian tube dysfunction (ETD), the patient had severe eardrum retraction and exposure of her implant.  The patient underwent a second surgery due to the implant exposure.  Over the intervening years, the patient has been treated repeatedly with nasal rinses, steroids and decongestants but her ETD and tympanic membrane (TM) retraction has persisted.  The patient has not improved with Valsalva.  The patient had a mastoid cleaning and Eustachian tube (ET) balloon dilation.  

This patient has an extraordinarily well documented chart with the same Ear Nose & Throat (ENT) specialist going back several years.  Through those years, the patient has had many and multiple treatments and surgeries for her ear issues.  The surgeon (and the records appear to confirm) describes that the patient has "adhesive left middle ear disease", "refractory to medical management."  When a patient has a recurrent problem requiring multiple surgeries and medications and is refractory to treatments, literature supports that alternatives can be considered.  

Though there is no 100% consensus on balloon therapy, there is repeated literature strongly indicating its efficacy on treating this patient's condition.  The surgeon made the comment that most otologists consider this procedure as a useful treatment option, which is a reasonable statement. Other than more surgeries and/or many more medications there are not many (if any) other treatments.  In essence this patient's middle ear needs a drain (i.e. the ET).  The patient's ET drain is and has not been working as evidenced by her repeated infections, her cholesteatoma, and her need for surgery, her conductive hearing loss and inability to Valsalva.  

As per literature review, there may not be a consensus until more studies are done but with a procedure that has very few side effects, that can be done in the office and that does give some (many) patients significant demonstrable (on tympanogram and Valsalva observation) improvement it would appear to be a worthwhile and medically indicated procedure. The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  There is literature supporting the use of ETD balloon. There is not total consensus but there are multiple articles supporting its use and efficacy. The device is approved by the Food and Drug Administration (FDA).

As per review of the medical record, this patient is a good candidate for balloon dilation of Eustachian tube, code 69799. This patient appears to have tried all the standard treatments (e.g., surgeries, medications) and the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for balloon dilation of Eustachian tube, code 69799 should be overturned.