MedicaidCoverageMedium impact
Minimally Invasive Sinonasal and Eustachian Tube Procedures - MEDICAID - SOUTH CAROLINA (New)
Humana·SC · ENT (Ear, Nose & Throat)·Medicaid
Effective date
Oct 28, 2026
We identified it
Oct 26, 2026
Summary
Humana South Carolina Medicaid establishes new coverage criteria for balloon dilation of the Eustachian tube (BDET) in adults aged 18+ with chronic obstructive ETD refractory to conservative management, requiring prior documentation of hearing evaluation, nasal endoscopy, and otoscopic examination. Posterior nasal nerve ablation procedures remain non-covered due to insufficient evidence.
Action Required
Effective 2026-10-28: (1) Billing team must implement prior authorization requirement for CPT 69705 (unilateral BDET) and 69706 (bilateral BDET) under Humana South Carolina Medicaid. (2) Verify member age ≥18 years and confirm documentation of three required pre-procedure elements (hearing evaluation, nasal endoscopic examination, otoscopic examination) is attached to authorization requests. (3) For members aged 18-20, flag requests for EPSDT medical necessity review per plan requirements. (4) Denial template for CPT 31242 and 31243 (posterior nasal nerve ablation) should cite insufficient evidence and absence of widely-accepted treatment guidelines; these codes remain non-covered. (5) Update authorization workflows in billing system to capture ETD duration (≥12 weeks) and documentation of management of contributing conditions (environmental irritants, LPR, nasal obstruction, rhinosinusitis). Failure to include required clinical documentation will result in claim denial.