Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic eustachian tube dysfunction
Treatment: Procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The insurer denied coverage for procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The denial is overturned 

This case involves an adult who underwent surgical intervention. A clinical note reported the patient was being seen for eustachian tube dilatory dysfunction and tinnitus. Examination noted retracted left tympanic membrane with serous fluid. The patient was recommended for balloon dilation. A letter from the patient stated that the patient had been suffering from various ear/sinus issues for many years. The patient reported symptoms included discomfort, pain, hearing loss, tinnitus, and ear fluid. The determination letter reported the requested procedure was denied as experimental/investigational. A letter of medical necessity reported the patient was suffering from eustachian tube dilatory dysfunction for many years with chronic middle ear effusions, chronic middle ear infections, significant middle ear pressure, and pain. Past treatment included prolonged use of nasal steroid sprays and placement of tympanostomy tubes on multiple occasions. It was noted while tubes were in place, the patient's symptoms were relieved, but that symptoms returned on extrusion. The provider stated further that repeated tympanostomy tube placement risked permanent injury to tympanic membrane. It was noted that balloon dilation of eustachian tube was a Food and Drug Administration (FDA)- approved procedure and there were several articles to support outcomes. 

Procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral) was considered more beneficial for this patient's diagnosis. There is scientific evidence in peer-reviewed literature to support a result of improvement in health outcome with balloon dilation for persistent eustachian tube dysfunction. The adverse risks are not increased over standard treatment/services. The FDA permits marketing of balloon device to treat persistent Eustachian tube dysfunction. The patient was a good candidate for procedure code 69706. The patient reported symptoms including discomfort, pain, hearing loss, tinnitus, and ear fluid. The patient was suffering from eustachian tube dilatory dysfunction for many years with chronic middle ear effusions, chronic middle ear infections, significant middle ear pressure, and pain. Past treatment included prolonged use of nasal steroid sprays and placement of tympanostomy tubes on multiple occasions. Therefore, procedure code 69706 was the best available treatment for this patient at that time. Overall, the requested service was likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral) and coverage for the requested service/treatment should be overturned. 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.