Myringotomy and Tympanostomy Tube (CPB 0418, reviewed 2026-06-30)
Summary
Aetna considers myringotomy and tympanostomy tube insertion medically necessary for cholesteatoma, chronic retraction of the tympanic membrane or pars flaccida, complications of otitis media such as meningitis, facial nerve paralysis, coalescent mastoiditis or brain abscess, and severe otalgia in acute otitis media. Tympanostomy tube insertion is medically necessary for otitis media with effusion lasting 3 months or longer with bilateral hearing impairment of 20 dB or worse in both ears, and for recurrent acute otitis media with more than 3 episodes in 6 months or more than 4 episodes in 12 months. Tympanostomy tube insertion is not medically necessary for a single episode of otitis media with effusion lasting less than 3 months, or for recurrent acute otitis media in children who have no middle ear effusion in either ear at the time of assessment for tube candidacy. Balloon dilation of the Eustachian tube is medically necessary for individuals 8 to 17 years of age, and for adults with chronic Eustachian tube dysfunction, when the listed criteria are met. Shim placement in the Eustachian tube is medically necessary for a patulous Eustachian tube. OtoScan laser-assisted myringotomy is considered as effective as traditional myringotomy, and the same selection criteria apply to both. Myringotomy and tympanostomy tube insertion for all other indications, soft-tissue fillers for a patulous Eustachian tube, phosphorylcholine-coated and vancomycin-coated tympanostomy tubes, the EarPopper device, balloon dilation of the Eustachian tube after an initially successful or unsuccessful balloon dilation, with tympanoplasty or other middle ear surgery, or for chronic ear disease, the Tubes Under Local Anesthesia (Tula) System, and the Hummingbird Tympanostomy Tube System are considered experimental, investigational or unproven.
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