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Date Printed: April 22, 2018: 05:39 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-31000-02

Original Effective Date: 04/15/18

Reviewed: 03/22/18

Revised: 00/00/00

Subject: Balloon Dilation of the Eustachian Tube

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates      
           

DESCRIPTION:

Eustachian tube dysfunction occurs when the functional valve of the eustachian tube fails to open and/or close properly. This failure is frequently due to inflammation and can cause symptoms such as muffled hearing, ear fullness, tinnitus, and vertigo. Chronic dysfunction can lead to hearing loss, otitis media, tympanic membrane perforation, and cholesteatomas.

Balloon dilation is a tuboplasty procedure intended to improve the patency of the cartilaginous eustachian tube. During the procedure, a saline-filled balloon catheter is introduced into the eustachian tube through the nose using a minimally invasive transnasal endoscopic method. Pressure is maintained for approximately 2 minutes after which the balloon is emptied and removed. The procedure is usually performed under general anesthesia.

POSITION STATEMENT:

Balloon dilation of the eustachian tube for treatment of members with chronic eustachian tube dilatory dysfunction is considered experimental or investigational. The durability of effect, rates of reoperation or revisions, and safety data over the first year are needed. The evidence is insufficient to determine the effects of the technology on long term health outcomes.

BILLING/CODING INFORMATION:

HCPCS Coding:

C9745

Nasal endoscopy, surgical; balloon dilation of eustachian tube (Investigational)

Unlisted CPT code 69799 may also be used to report balloon dilation of the eustachian tube.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy Reference Manual 7.01.158 Balloon Dilation of the Eustachian Tube, 02/2018.
  2. Bowles PF, Agrawal S, Salam MA, Balloon tuboplasty in patients with Eustachian tube dysfunction: a prospective study in 39 patients (55 ears). Clin Otolaryngol. 2017 Oct;42(5):1057-1060.
  3. ClinicalTrials.gov, Balloon Dilation of the Eustachian Tube, a Lower Pressure Challenge, sponsored by Hillel Yaffe Medical Center.
  4. ClinicalTrials.gov, Long Term Evaluation of Tubal Expansion on Obstructive Dysfunctions of Eustachian Tube, sponsored by University Hospital, Montpellier.
  5. National Institute for Health and Care Excellence. Balloon Dilation of the Eustachian tube [IPG 409], 2011; accessed at nice.org.uk.
  6. Teschner M, Evidence and evidence gaps in the treatment of Eustachian tube dysfunction and otitis media. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2016 Dec 15;15:Doc05.
  7. U.S. Food & Drug Administration (FDA), ACCLARENT AERA® Eustachian Tube Balloon Dilation System; accessed at fda.gov.
  8. U.S. Food & Drug Administration (FDA), XprESS ENT Dilation System; accessed at fda.gov.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the Florida Blue Medical Policy & Coverage Committee on 03/22/18.

GUIDELINE UPDATE INFORMATION:

04/15/18

New Medical Coverage Guideline.

Date Printed: April 22, 2018: 05:39 PM