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.

The patient is a female with a history of eustachian tube dysfunction (ETD). She presented to the Otolaryngologist's office with complaints of bilateral tinnitus and otalgia. The provider noted that the patient is currently taking antibiotics and steroids. Tinnitus has been present for years. Computed Tomography (CT) did not reveal evidence of acute or chronic sinus disease. Audiogram revealed flat tympanograms which confirmed she is a candidate for eustachian tube dilation. The physician recommended eustachian tube dilation. The physician did discuss treatment options other than tympanostomy tube placement. The patient was seen for preop clearance. She underwent bilateral eustachian tube dilation and insertion of tympanostomy tube. Surgery was uneventful.

There is scientific evidence in peer reviewed literature to support and substantiate its improvement in health outcomes as well as its safety and effectiveness. As a sample, for example Tucci et al noted in "Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube" that the panel reached consensus on several statements that clarify diagnosis and perioperative management of obstructive eustachian tube dysfunction (OETD). They did note that consensus was that balloon dilation of the eustachian tube (BDET) is an option for treatment of patients with ETD. Furthermore, Poe et al noted in "Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial" that the objective was to assess balloon dilation of the eustachian tube with eustachian tube balloon catheter in conjunction with medical management as treatment for eustachian tube dilatory dysfunction. They performed a prospective, multicenter, randomized, controlled trial, and demonstrated superiority of balloon dilation of the eustachian tube with balloon catheter  plus medical management compared to medical management alone to treat eustachian tube dilatory dysfunction in adults. Huisman et al noted in " Treatment of Eustachian tube dysfunction with balloon dilation: A systematic review" that the aim was  to perform a systematic review to evaluate the success of balloon dilation of the tube in reducing symptoms in adult patients with eustachian tube dysfunction. The data sources were: Embase, PubMed, and Cochrane Library. The authors found 36 articles of which 15 were eligible for critical appraisal. They concluded all current studies suggest that balloon dilation of the eustachian tube can be a helpful treatment in patients with eustachian tube dysfunction. 

This procedure is Food and Drug Administration (FDA) approved. It appears that this patient is a good patient for this device given the fact that the patient has a flat tympanogram and has chronic otalgia without any evidence of sinus disease and has been treated medically without improvement. The procedure is likely to be more beneficial than standard treatment which has not been successful in this patient. The risks are not substantially increased over standard treatment services. The procedure should not be considered experimental/investigational. 

Based upon the records, the balloon dilation should be approved, as it is FDA approved and has shown good results in randomized clinical trials and there is peer reviewed literature to substantiate the improved results. 

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