Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Eustachian Tube Dysfunction. 

Treatment: Code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The insurer denied coverage for code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

The denial is overturned. 

This case involves a patient regarding the denial of coverage for code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). The progress notes noted the patient was being seen for chronic maxillary rhinosinusitis. The patient had right endoscopic sinus surgery with bilateral maxillary hardware removal. The patient developed blepharitis of the left upper and lower eyelids. It was felt that the patient had blepharitis of an unknown cause and the patient eventually underwent biopsy with oculoplastic surgery. It was felt that the blepharitis was secondary to doxycycline drug reaction for which the patient was prescribed to treat acne. The patient was no longer taking doxycycline and symptoms were improving.  However, the patient was having intermittent nasal obstruction worsening the right side, occurring in the morning, with congestion on both sides. The patient used Flonase with some benefit but continued to have popping of the ears on both sides. The patient also had right facial fullness sensation from time to time. The patient's Asceniv 2-22 score was 24, and Snoring Index (SI) score was 13, and Sinus Control Test (SCT) was 9. The patient had moderate facial sinus pressure, facial or sinus pain, and headache with mild nasal congestion, nasal obstruction, postnasal drip, clear nasal discharge, itchy nose/eyes/throat, tiredness, and cough. The patient had a history of strep throat multiple along with sinus infection with a sinus cyst and cough. On physical examination, the patient's vital signs were stable. The patient's septum deviated to the left with no other significant abnormalities noted on assessment. The assessment was probable odontogenic cyst of the right maxillary sinus and history of right maxillary/cheek swelling along with recurrent sinonasal and oropharyngeal infections. The patient was status post right endoscopic sinus surgery with maxillary antrostomy, anterior ethmoidectomy, frontal sinusotomy, and marsupialization of probable odontogenic cyst to the nasal cavity. The patient had bilateral eustachian tube dysfunction with right greater than left nasal congestion/obstruction. The patient had infected hardware screw tips of the right maxillary sinus status post bilateral maxillary hardware removal and chronic right maxillary and frontal rhinosinusitis. 

Code 69705, an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear), has final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for code 69705, an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear). 

Code 69705, an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear), is one of the best available treatments for this patient at this time. 

The adverse risks are not increased over standard treatment/services. 

The requested service is likely to be as beneficial or more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of code 69705 an outpatient Nasopharyngoscopy surgical with dilation of eustachian tube (procedure done in the ear) and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.