Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic eustachian tube dysfunction
Treatment: Procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The insurer denied coverage for procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The denial is overturned 

This case involves an adult who was diagnosed with eustachian tube dilatory dysfunction despite treatment with Nasacort and saline gel. Symptoms had persisted for several years with chronic middle ear effusions and infections. Symptoms included increased pain and pressure with elevation changes and pressure changes during travel.  The patient previously underwent placement of tympanostomy tubes on multiple occasions which were effective in relieving symptoms, but upon extrusion, symptoms returned, and the condition failed to improve. The treating physician stated that the usefulness of the tubes had been exhausted and further repeated tympanostomy tube placement risked injury to the tympanic membrane that could require major tympanoplasty reconstructive surgery. The physician recommended balloon dilation of the eustachian tube with reports that this was an FDA (Food and Drug Administration) approved procedure to treat chronic eustachian tube dilatory dysfunction in patients aged 22 and older. The patient received a notice of adverse determination indicating that the nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral procedure was experimental and not a covered service. The service was denied based on clinical policy bulletin (CPB) #0418, Myringotomy and Tympanostomy Tube.  This review pertains to the denial of coverage for procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral).

The scientific evidence in the peer-reviewed literature supports a result of improvement in health outcome.

The request has final approval from the appropriate regulatory bodies for this diagnosis.

The patient was a good candidate for procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral).

Given the patient's prior treatment history, procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral) was considered the best available treatment for this patient at that time.

The adverse risks are not increased over standard treatment/services.
The requested service is likely to be as beneficial or more beneficial as other standard treatment/procedures for this patient.

Current medical literature states that balloon dilation is a safe and effective treatment for persistent eustachian tube dysfunction. The Food and Drug Administration (FDA) approved eustachian tube balloon dilation in 2016, indicating that the safety and effectiveness of the procedure was verified. Records provided for the review noted that the patient remains symptomatic despite conservative efforts to treat her eustachian tube dilatory dysfunction. It was therefore determined that proceeding with the balloon dilation was supported. As such, the prior determination is overturned.

In summary, the denial of procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral) and coverage for the requested service/treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.