CG-SURG-46 Myringotomy and Tympanostomy Tube Insertion

This policy addresses myringotomy and tympanostomy tube insertion for middle ear conditions. Combined myringotomy with tympanostomy tubes is medically necessary for: (1) children or adults with recurrent acute otitis media (>3 episodes/6 months or >4/12 months) who have middle-ear effusion at the time of assessment; (2) children with unilateral or bilateral otitis media with effusion persisting ≥3 months with hearing loss >20 dB; or (3) children with recurrent AOM or OME of any duration who are at risk for speech, language, or learning delay (e.g., confirmed delay, autism spectrum disorder, Down syndrome/craniofacial syndromes). Myringotomy alone and the combined procedure are not medically necessary when these criteria are not met or for all other indications.

"The use of combined myringotomy and tympanostomy tube insertion is consideredmedically necessaryfor individuals who meet any of the following criteria:"