Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ears/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied nose surgery. 
The denial is overturn.

The patient is a male with a history of bilateral myringotomy and tube placement, tympanoplasty, along with ear pressure, otalgia and eustachian tube dysfunction. He has a multiyear history of chronic eustachian tube dysfunction, allergic rhinitis, and history of several sets of myringotomy and tubes along with a tympanoplasty on the left side. Two years prior he had a eustachian tube dilation of bilateral tubes.  The surgeon was unable to get access to the eustachian tube because of a septal deviation his exam showed fluid behind tympanic membranes with chronic serous otitis media. The audiogram showed a left and right conductive hearing loss and type B tympanograms. He has been on antibiotics. Physical exam showed retraction of the eardrum and obstruction of bilateral eustachian tubes. Included in the records were studies done on eustachian tube balloon dilation presumably from the physician. Multiple audiograms are present in the records showing bilateral hearing loss and type B tympanograms. The subject under review is whether the requested procedure is likely to be more beneficial for this patient's condition.

The requested procedure is likely to be more beneficial for this patient. This patient has a documented history of chronic middle ear issues. He has had multiple myringotomy and tubes and has had tympanoplasty according to the records. He has been on antibiotics. He also has a deviated septum. Prior exam showed fluid in the middle ear along with a severely deviated septum. He had multiple audiograms which showed conductive hearing loss bilateral along with type B tympanograms. All this is consistent with the client receiving maximal medical treatment but have been persistent and refractory eustachian tube dysfunction and middle ear issues. His physical exam showed a retracted eardrum, and the repeat myringotomy and tubes are indicative of eustachian tube and middle ear issues. His options at this point are very limited and really consist of repeat myringotomy and tubes. Repeat myringotomy and tubes in patients can have risks and complications such as persistent perforation, cholesteatoma, and hearing loss. Typical criteria for eustachian tube balloon dilation include; repeat myringotomy and tubes and otitis media, hearing loss on audiogram and tympanogram, abnormal retracted eardrums, ruling out other pathologies chronic and persistent eustachian tube dysfunction for a significant amount of time. His history and the records fulfill all of these typical requirements.
The denial by the plan that the eustachian tube balloon dilation is experimental is not congruent with the literature, and with standard practice by many ear nose and throat physicians. This procedure is being done commonly by ear, nose, and throat (ENT) physicians, has been shown to be efficacious, long-lasting, and resulting improvement in the patient's complaints. Therefore, the eustachian tube balloon dilation and no surgery nasopharyngoscopy are likely to be more beneficial than standard treatment for this patient's condition.