Balloon dilation of the eustachian tube (BDET) for treatment of chronic obstructive eustachian tube dysfunction (ETD) may be considered medically necessary under the following conditions:
Adults (age 22 years and older) with symptoms of obstructive eustachian tube dysfunction (aural fullness, aural pressure, otalgia, and/or hearing loss) for 12 months or longer in one or both ears that significantly affects quality of life or functional health status
Aural fullness and pressure must be present (see Policy Guidelines)
AND
The patient has undergone a comprehensive diagnostic assessment; including patient-reported questionnaires, history and physical exam, tympanometry if the tympanic membrane is intact, nasal endoscopy, and comprehensive audiometry, with the following findings:
Abnormal tympanogram (Type B or C)
Abnormal tympanic membrane (retracted membrane, effusion, perforation, or any other abnormality identified on exam)
AND
Failure to respond to appropriate medical management of potential co-occurring conditions, if any, such as allergic rhinitis, rhinosinusitis, and laryngopharyngeal reflux, including 4-6 weeks of a nasal steroid spray, if indicated
AND
Other causes of aural fullness such as temporomandibular joint disorders, extrinsic obstruction of the eustachian tube, superior semicircular canal dehiscence, and endolymphatic hydrops have been ruled out.
AND
If the individual had a history of tympanostomy tube placement, symptoms of obstructive ETD should have improved while tubes were patent.
AND
The individual does not have patulous ETD or another contraindication to the procedure (see Policy Guidelines).
AND
The individual’s ETD has been shown to be reversible (see Policy Guidelines).
AND
Symptoms are continuous rather than episodic (e.g., symptoms occur only in response to barochallenge such as pressure changes while flying).
AND
The individual has not had a previous BDET procedure.
Balloon dilation of the eustachian tube is considered investigational if the above criteria are not met.
