Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fluid Behind Right Eardrum
Treatment: Eustachian Tube Dilation System
The insurer denied: Eustachian Tube Dilation System
The denial is overturned.

The patient is an elderly female with a history of bilateral chronic Eustachian tube dysfunction (ETD). The patient reports symptoms of aural fullness, pressure, and autophony. The patient states the symptoms and bilateral chronic Eustachian tube dysfunction began in her mid-30s. The patient reports having tried conservative therapies over the years, including oral decongestants and intranasal steroid sprays. The episodes can be short-term or can persist over weeks-months. The patient indicates her hearing function is fine between episodes/flares of Eustachian tube dysfunction. When the patient has episodes/flares of Eustachian tube dysfunction, her hearing becomes muffled. This has impacted her work/profession. The patient also reports having pulsatile tinnitus at night that accompanies the episodes/flares of Eustachian tube dysfunction. The patient notes having attendant anxieties around the prospect of Eustachian tube dysfunction events occurring. Last year, the patient had a persistent case of Eustachian tube dysfunction that was unresponsive to intranasal steroids, oral steroids, and a course of antibiotics. The patient was evaluated by an otolaryngologist, who performed a bilateral myringotomy 10 months ago. Subsequently, the patient reported undergoing five additional myringotomies and pressure equalizing (PE) tube placement. The records provided indicate at least three separate myringotomies this year. An audiogram 10 months ago indicates a type B tympanometry on the right and a type B tympanometry on the left with both having negative pressure. The hearing thresholds indicate a mild conductive hearing loss bilaterally. An audiogram 7 months ago indicates a type B tympanometry on the right and a type A tympanometry on the left with negative pressure. An audiogram on 9 months ago indicates a type B tympanometry on the right and a type C tympanometry on the left with negative pressure. A physical examination 9 months ago indicated air-fluid levels and a middle ear effusion. The right ear was normal. An audiogram 7 months ago indicates a type B tympanometry on the right and a type A tympanometry on the left with negative pressure. A physical examination 7 months ago indicated a dull tympanic membrane on the left with low mobility and middle ear effusion. The right ear was normal. Given the refractory nature of the patient's Eustachian tube dysfunction, Eustachian tube dilation has been recommended. 

The Eustachian Tube Dilation System is medically necessary.

Eustachian tube dilation is a minimally invasive procedure that can be used to treat chronic obstructive eustachian tube dysfunction (ETD). Eustachian tube dysfunction is a condition in which the Eustachian tubes, which connect the middle ear to the throat, do not open and close properly. This can lead to a variety of symptoms, including ear fullness, muffled hearing, tinnitus (ringing in the ears), and vertigo. Medical management is the first line of treatment for Eustachian tube dysfunction. This may include medications such as decongestants, antihistamines, and nasal steroids. However, some patients do not respond to medical management, or their symptoms are severe enough to warrant more aggressive treatment. A number of studies have shown that Eustachian tube dilation is effective in relieving symptoms and improving quality of life in patients with chronic obstructive Eustachian tube dysfunction. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recommends Eustachian tube dilation as a treatment option for patients with chronic obstructive Eustachian tube dysfunction who have failed to respond to medical management. Eustachian tube dilation is a safe and effective procedure that can significantly improve quality of life in these patients. In this patient's case, she has maximized conservative therapy, which includes intranasal steroids, oral decongestants, and repeated myringotomies. Therefore, the requested health service is medically necessary.