Tympanostomy Tubes

Coverage decision: Covered with conditions

In Adults

L&I may pay for tympanostomy tubes in injured workers (aged 17 and older) on a case by case basis when work-relatedness is established and otitis media is an accepted diagnosis on the claim.

In Children

Tympanostomy tubes for children aged 16 years and younger is a covered benefit with conditions when work-relatedness is established and otitis media is an accepted diagnosis on the claim.

Conditions of Coverage

  • Acute Otitis Media (AOM)
    • Cover if AOM with complications or in immunocompromised individuals or otherwise at-risk for complications of infection, OR
    • With 3 episodes of AOM in the last 6 months or 4 episodes in last 12 months with one occurring in the last 6 months and presence of effusion at the time of assessment for surgical candidacy.
  • Otitis Media with Effusion (OME)
    • Cover if the duration of effusion is 3 months or greater, AND there is documented hearing loss, OR
    • At-risk children:
      • Children at risk for persistent effusion based on anatomic abnormalities, OR
      • Children at disproportionate risk of hearing loss, such as speech delay, underlying sensory-neuro hearing loss, or cognitive disorders.

Background Information

The State Health Technology Clinical Committee (HTCC) reviewed tympanostomy tubes in children in November 20, 2015. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that tympanostomy tubes in children aged16 and younger is a covered benefit with conditions. Complete information on this HTCC determination is available here: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews

Implementation of the Coverage Decision

All requests for tympanostomy tubes require prior authorization. The procedure may be used only for care of a condition accepted on the claim. 

For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultants and claim managers.

  • Complete the Preauthorization Form and fax to: 360-902-4567
  • For additional information contact the claim manager
    • To obtain the claim manager’s phone number call 1-800-831-5227
    • Attending or concurrent care provider log into the Claims & Account Center (CAC)

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

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