Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eustachian tube dysfunction and otitis media 
Treatment: Surgical Services/Eustachian Tube Balloon Dilation
The health plan denied the requested Eustachian Tube Balloon Dilation as  not medically necessary. 
The health plan's determination is overturned.

Records indicate this is a male who has a history of adhesive otitis media bilaterally. There are records and notation of prior visits. Diagnosis includes adhesive middle ear disease, chronic bilateral otitis media, low-frequency hearing loss conductive hearing loss and dysfunction of both eustachian tubes. His history also includes a myringotomy with tube on the right side and also on the left side and a bilateral myringotomy. There is also notation that there is a later myringotomy. A computerized axial tomography (CAT) scan was ordered and noted in the telemedicine visit and the report is present noting retraction of the eardrums and an otherwise normal exam. There is an audiogram present showing bilateral hearing loss more on the left. Further records note the left ear fullness and pressure and notation of a suggestive patulous eustachian tube, but in the past. The hearing test showed a flat tympanometry bilaterally with conductive hearing loss. Exam showed left ear fluid "fills the middle ear "with retraction and on the right myringotomy tube in place. There are notes an audiogram noting the same history at this point the hearing was better than it was in earlier testing. There are records with the same history going back and the use of medication such as Fluticasone is noted.
At issue is the medical necessity for the requested eustachian tube balloon dilation.

The health plan's determination of medical necessity is overturned, in whole.

This patient has a very well-documented history of otitis media. He has had multiple myringotomy and tubes. The patient has been diagnosed with eustachian tube dysfunction and otitis media and adhesive otitis media. He has audiograms going back, documenting his hearing loss and otitis.

This patient appears to have a history that fulfills all typical criteria. As noted below, the procedure is not considered by many ear, nose, and throat (ENT) physicians, and multiple insurances and the literature as being unproven. This patient's options are very limited. He can continue to have medications, but this most likely will not work and will be permanent; he can continue to have myringotomies, but this itself can cause complications. Without this procedure he will be relegated to repeat myringotomies, repeat otitis media and significant issues with quality of life. This all appears to be consistent with the procedure being a standard of care for many ENT physicians, supported by literature and medically necessary.

Balloon dilation of the eustachian tube, when done in appropriate patients has been found to be efficacious, durable and medically appropriate. Many health plans now consider it medically necessary in appropriate patients. The literature supports its efficacy, durability, results and patient satisfaction. It is worth noting that patients who require eustachian balloon dilation have been plagued with ear problems, can have reduced hearing, recurrent infections and very significant quality of life issues. These patients often have no alternatives other than having persistent ear infections and ear problems for years. The treatment is being done regularly by many ENT physicians and is medically necessary, appropriate and standard of care for appropriate patients. 

Eustachian tube balloon dilation appears to be associated with improvement in subjective and objective treatment outcome metrics. The improvement appears stable at 3 to 12 months after dilation. Patients with eustachian tube dysfunction are likely to benefit from balloon dilation, particularly those with medication-refractory disease. [4]