MedicaidCoverageMedium impact
Minimally Invasive Sinonasal and Eustachian Tube Procedures - MEDICAID - VIRGINIA (New)
Humana·VA · ENT (Ear, Nose & Throat)·Medicaid
Effective date
Oct 28, 2026
We identified it
Oct 26, 2026
Summary
Humana Virginia Medicaid establishes new coverage policy for minimally invasive sinonasal and Eustachian tube procedures, effective 10/28/2026. Balloon dilation of the Eustachian tube (BDET) is covered for adults 18+ with chronic obstructive ETD meeting specific clinical criteria; posterior nasal nerve ablation is NOT covered due to insufficient evidence. Billing teams must implement coverage criteria checks and prior authorization workflows for the two covered CPT codes.
Action Required
Effective 2026-10-28: Billing team must implement coverage criteria verification and prior authorization requirements for Virginia Medicaid claims. For CPT codes 69705 and 69706 (BDET procedures), require documentation of: (1) patient age 18+, (2) chronic obstructive ETD lasting >12 weeks despite management of contributing conditions, (3) detailed history and physical with hearing evaluation, nasal endoscopic examination, and otoscopic examination before claim submission. Deny or request medical necessity review for members under age 21 per EPSDT requirements. Implement hard edit in billing system to deny claims for CPT codes 31242 and 31243 (posterior nasal nerve ablation) as non-covered services, with explanation: insufficient evidence for standard medical treatment. Front office and prior authorization staff should be trained on these requirements to prevent claim denials.