69421
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.74
Facility
$137.95
Non-Facility
$137.95
Key Coverage Criteria
- The use of combined myringotomy and tympanostomy tube insertion is consideredmedically necessaryfor individuals who meet any of the following criteria:
- Children or adults with recurrent acute otitis media (AOM) (more than 3 episodes in 6 months or more than 4 episodes in 12 months) with or without otitis media with effusion (OME) who have middle ear effusion at the time of assessment for tube candidacy;or
- Children with unilateral or bilateral OME for greater than or equal to 3 months with hearing loss greater than 20 dB in one or both ears;or
- Individual who meets criteria for tympanostomy and tube insertion but for whom tube insertion is not feasible due to the degree of ear inflammation.
- Children with recurrent AOM or OME of any duration when the child is at risk for speech, language, or learning delay or disorder from OM based on baseline sensory, physical, cognitive, or behavioral factors including, but not limited to, the following:Confirmed speech or language delay or disorder.Autism spectrum disorder or other pervasive developmental disorder.Syndromes (for instance, Down) or craniofacial disorders that include cognitive, speech, or language delays.Intellectual disability, l [...]
- Confirmed speech or language delay or disorder.
1 Active Policy
ANTHEM-CG-SURG-46 — CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion
Related Codes
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