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ICD-10-CM H65.499, Other chronic nonsuppurative otitis media, unspecified ear | No Prior Auth

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`H65.499`, Other chronic nonsuppurative otitis media, unspecified ear

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Key Coverage Criteria

A single treatment of unilateral or bilateral balloon dilation of the Eustachian tubes via nasal endoscopy is consideredmedically necessarywhenallthe following criteria are met for the ear(s) to be treated (A, B, C, D, and E):
The individual is 18 years of age or older;and
The individualâs history and physical exam includeallthe following (1, 2, 3, and 4):Eustachian tube dysfunction:Has been present for 3 months or more;andPersists despite medical therapy of any associated conditions (if present) such as allergic rhinitis, rhinosinusitis, or laryngopharyngeal reflux;andOtoscopic examination shows either of the following (i or ii):Persistent otitis media with effusion;orTympanic membrane retraction;andNasal endoscopic examination does not show physical obstructio [...]
Eustachian tube dysfunction:Has been present for 3 months or more;andPersists despite medical therapy of any associated conditions (if present) such as allergic rhinitis, rhinosinusitis, or laryngopharyngeal reflux;and
Has been present for 3 months or more;and
Persists despite medical therapy of any associated conditions (if present) such as allergic rhinitis, rhinosinusitis, or laryngopharyngeal reflux;and

1 Active Policy

ANTHEM-CG-SURG-117, Balloon Dilation of the Eustachian Tubes

Related Codes

69705(1 policies)69706(1 policies)A4818(1 policies)H65.20(1 policies)H66.10(1 policies)H66.3X9(1 policies)H66.90(1 policies)00151(1 policies)

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