Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Tympanostomy tube insertion is a surgical treatment for persistent otitis media with effusion and recurrent acute otitis media. The tubes inserted in the tympanic membrane equalize middle ear pressure with atmospheric pressure and allow fluid drainage, which alleviates symptoms of otitis media. Otitis media occurs primarily in childhood, and is rarely a work-related condition.
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.
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.
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 aged 16 and younger is a covered benefit with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority
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.