MedicaidCoverageMedium impact
Minimally Invasive Sinonasal and Eustachian Tube Procedures - MEDICAID - ILLINOIS (New)
Humana·IL · ENT (Ear, Nose & Throat)·Medicaid
Effective date
Oct 28, 2026
We identified it
Oct 26, 2026
Summary
Humana Illinois Medicaid establishes new coverage criteria for minimally invasive sinonasal and Eustachian tube procedures. Balloon dilation of the Eustachian tube (BDET) is covered for adults 18+ with chronic obstructive ETD lasting >12 weeks despite management of contributing conditions, when supported by hearing evaluation, nasal endoscopy, and otoscopic examination. Posterior nasal nerve ablation procedures are NOT covered due to insufficient evidence.
Action Required
Effective 2026-10-28: Billing team must update coverage and authorization protocols for Illinois Medicaid claims. (1) For CPT 69705 and 69706 (BDET, unilateral and bilateral): Implement prior authorization review requiring documentation of chronic obstructive ETD lasting >12 weeks, management of contributing conditions (environmental irritants, laryngopharyngeal reflux, nasal obstruction, or rhinosinusitis), hearing evaluation, nasal endoscopic examination, and otoscopic examination. Age verification (18+) is mandatory; requests for members under 21 must be reviewed for EPSDT medical necessity. (2) For CPT 31242 and 31243 (posterior nasal nerve ablation): Update billing system to deny coverage with reason code indicating non-covered service per policy HUM-IL-2666-000; do not process prior authorization requests. (3) Billing and clinical teams should verify these criteria are incorporated into encounter forms and pre-authorization workflows in the practice management system. (4) Communicate updated policy to providers to ensure proper documentation at time of service, as claims lacking required clinical documentation will be denied.