Medical Policy: 08.01.25 

Original Effective Date: April 2017 

Reviewed: April 2018 

Revised: April 2018 

 

Benefit Application:

Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

 

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

 

Description:

The Eustachian tube is formed by an osseous part and a fibrocartilaginous part. Its function is to provide ventilation, drainage, and protection to the middle ear, as well as maintaining the same pressure present in the external environment (atmospheric pressure) in the tympanic cavity.

 

Eustachian tube dysfunction (ETD) is a common clinical condition of the middle ear that can affect patients of all ages. ETD occurs if the Eustachian tube becomes blocked, if the lining of the tube swells, or if the tube does not open fully to allow air to travel to the middle ear. The causes of ETD are both extrinsic and intrinsic to the Eustachian tube. The symptoms are hearing loss, dull hearing, and very rarely ear pain. These symptoms can occur when carrying out a variety of activities including air travel, mountain hiking, swimming, and diving activities. An important limitation with the available evidence is a lack of consensus on the definition and diagnosis of this disorder. Although in a strict sense Eustachian tube dysfunction is a failure to perform any of the Eustachian tube functions, in clinical practice, Eustachian tube dysfunction usually refers to a problem with the ventilatory function of the Eustachian tube. Otitis media with effusion (OME) is defined as a collection of fluid in the middle ear without signs or symptoms of ear infection and typically arises when the Eustachian tubes are not functioning normally. As such, Eustachian tube dysfunction is defined by symptoms and signs of pressure dysregulation in the middle ear. This can be both an acute or chronic (more than 3 months of signs and symptoms) condition. In many cases, the ETD is mild and does not last longer than a few days or a week.

 

Ear Popper® (autoinflation)

The EarPopper® is a non-invasive device for treating conditions such as otitis media with effusion, middle ear effusion, aerotitis/barotitis and eustachian tube dysfunction, without the need for surgery or antibiotics. The EarPopper® balances pressure in the middle ear by delivering a constant stream of air into the nasal cavity. During the moment of swallowing, the air opens the Eustachian Tube, clearing the middle ear, relieving negative ear pressure and allowing any fluids to drain.

 

Eustachian Tube Tuboplasty

Balloon Tuboplasty or Eustachian tube tuboplasty is a procedure recently approved by the FDA. This procedure uses a modified catheter that is introduced inside the Eustachian tube, using a special microendoscope to allow positioning. Once the catheter is introduced, the balloon located on its distal end is inflated by introducing saline solution. This pressure is kept unvaried for two minutes. Then, the balloon is deflated and the catheter is removed under endoscopic vision.

 

Currently the ACCLARENT AERA™ Eustachian Tube Balloon Dilation System and the XprESS™ ENT Dilation System (Entellus Medical, Plymouth, MN) are approved by the U.S. Food and Drug Administration (FDA) for Eustachian Tube Dysfunction (ETD).

 

The evidence for balloon dilation for eustachian tube dysfunction (ETD) consists of case series, systematic reviews of these case series, and a 2017 RCT. The only available comparative data derive from a single multicenter RCT. The endpoints for the randomized portion of this study were short-term (i.e., six-week) measures of efficacy, quality of life, and safety. According to the FDA Summary of Clinical Information, efficacy data demonstrated a degree of site variation concerning the treatment effect, with two sites reporting a higher percentage of tympanogram normalization for patients medically managed than for treated patients after six weeks.

 

NICE (National Institute for Health and Clinical Excellence)

Balloon dilatation of the Eustachian tube should only be used in the context of research, which should address the efficacy of the procedure in the short and longer term, and also document safety outcomes. Research studies should clearly describe which parts of the Eustachian tube are being treated and report subjective measurements of symptom improvement and objective measurements of Eustachian tube function. Current evidence on the efficacy and safety of balloon dilatation of the Eustachian tube is inadequate in quantity and quality.

 

Rationale

Given the natural history of OME/ Eustachian tube dysfunction, particularly in relation to the high instance of spontaneous resolution, clinical decisions are complicated, and despite recent practice guidelines and systematic reviews, the comparative benefits and harms of treatments and treatment strategies for OME/Eustachian tube dysfunction are uncertain. There is no consensus on indications for treatment, or on the optimal timing of the interventions. The longevity of symptom management is uncertain for both the auto inflation and Eustachian tube tuboplasty procedures.

 

Prior Approval:

Not applicable.

 

Policy:

The EarPopper device for the treatment of otitis media with effusion and Eustachian tube dysfunction or any other condition is considered investigational.

 

The use of the Eustachian tube balloon dilation system for Eustachian tube dysfunction or any other condition is considered investigational.

 

Procedure Codes and Billing Guidelines:

To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes and / or diagnosis codes.

  • C9745 Nasal endoscopy, surgical; balloon dilation of eustachian tube
  • 69799 Unlisted procedure, middle ear
  • E1399 (used for the at home EarPopper®)

 

Selected References:

  • Banigo A, Hunt A, Rourke T, et al. Does the EarPopper(®) device improve hearing outcomes in children with persistent otitis media with effusion? A randomised single-blinded controlled trial. Clin Otolaryngol. 2016;41(1):59-65.
  • Yegin Y, Çelik M, Olgun B, et al. Is ventilation tube insertion necessary in children with otitis media with effusion? Otolaryngol Pol. 2015;69(6):39-44.
  • National Institute for Health and Clinical Excellence (NICE). Surgical management of otitis media with effusion in children. NICE Clinical Guideline 60. London, UK: NICE; February 2008.
  • National Institute for Health and Care Excellence. Balloon Dilation of the Eustachian tube [IPG 409]. 2011.
  • Shekelle P, Takata G, Chan LS, et al. Diagnosis, History, and Late Effects of Otitis Media With Effusion. Evidence Report/Technology Assessment No. 55 (Prepared by Southern California Evidence-based Practice Center under Contract No 290-97-0001, Task Order No. 4). Rockville, MD: Agency for Healthcare Research and Quality; 2003. AHRQ Publication No. 03-E023.
  • Agency for Healthcare Research and Quality. Otitis media with effusion: Comparative effectiveness of treatments. August 7, 2012. AHRQ: Rockville, MD.
  • BMJ Publishing Group Ltd. Eustachian Tube Dysfunction. 2012.
  • Schilder A, Bhutta M, Butler C, et al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clinical Otolaryngology. 2015;40(5):407-411.
  • Adil E. Poe D. What is the full range of medical and surgical treatments available for patients with Eustachian tube dysfunction? Curr. Opin. Otolaryngol. Head Neck Surg. 2014;22:8–15.
  • Doyle WJ, Swarts JD, Banks J, et al. Sensitivity and specificity of eustachian tube function tests in adults. JAMA Otolaryngol. Head Neck Surg. 2013;139:719–727.
  • FDA Approval Medical Devices; Ear, Nose, and Throat Devices; Classification of the Eustachian Tube Balloon Dilation System. Federal Register / Vol. 81, No. 205 / Monday, October 24, 2016.
  • Huisman JML, Verdam FJ, Stegeman I, et al. Treatment of Eustachian tube dysfunction with balloon dilation: A systematic review. Laryngoscope. Jan 2018;128(1):237-247. PMID 28799657
  • Poe D, Anand V, Dean M, et al. Balloon dilation of the eustachian tube for dilatory dysfunction: A randomized controlled trial. Laryngoscope. Sep 20 2017. PMID 28940574
  • Food and Drug Administration. 510(k) Summary: XprESS ENT Dilation System. 2017.
  • Food and Drug Administration. De Novo Classification Request For Acclarent Aera™ Eustachian Tube Balloon Dilation System. 2015,
  • ECRI Institute, Custom Product Briefs. Acclarent Aera Eustachian tube balloon dilation system for treating persistent Eustachian tube dysfunction. 3/6/2018.

 

Policy History:

April 2018 - Annual Review, Policy Revised

April 2017 - New Policy

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

 

*CPT® is a registered trademark of the American Medical Association.