Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement  for ear tube placement without anesthesia.  Findings:  Three physician reviewers found that the enrollee has diagnoses of recurrent acute serous otitis media, bilateral chronic serous otitis media, and conductive hearing loss.  She has experienced recurrent ear infections, and middle ear effusions which are impacting her gross motor function and speech.  The otolaryngologist performed a baseline audiogram that revealed mild conductive hearing loss bilaterally.  The physician discussed the placement of ear tubes for this enrollee, as the chronic ear infections could result in further hearing loss. The enrollees mother did not wish to proceed with surgery at that time. A repeat audiogram revealed mild but rising conductive hearing loss, suggestive of middle ear pathology.  On the next visit with the otolaryngologist, one to two episodes of acute otitis media had occurred since the last visit. These were treated with antibiotics and homeopathic remedies. Examination showed mucoid fluid in the middle ear space bilaterally and decreased mobility on pneumatic otoscopy.  Based on audiogram results, exam findings, hearing loss, young age, day-care exposure, the recommendation was for bilateral myringotomy with ear tube placement.  The enrollees parents had safety concerns with use of anesthesia due to family history of serious adverse reactions to anesthesia. Thus, the enrollee was referred to an out-of-network otolaryngologist who performs the procedure without anesthesia, as this procedure is not available without anesthesia through in-network providers.  The procedure was performed without complications by the out-of-network provider. Studies showing ear tube placement have been done with anesthesia in children.  In adults and children who are able to tolerate tube placement without anesthesia, the procedure is done with equal efficacy to tube placement under anesthesia. There is no proof that performing ear tube placement in children without anesthesia is more beneficial or safer. The procedure of placing tubes is exactly the same either way. Although the enrollee meets criteria for bilateral myringotomy with ear tube placement based upon history, physical exam and speech delay, there is no evidence that ear tube placement without anesthesia is likely to be more beneficial. Tympanostomy in children usually requires general anesthesia with the operation taking about ten to twenty minutes. There were no exceptional factors in the medical record to support the performance of the procedure without anesthesia. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in otolaryngology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.