Is a tympanoplasty without mastoidectomy (CPT code 69633) medically necessary for a patient with right chronic otitis media and right conductive hearing loss?

Medical Necessity Assessment for Tympanoplasty Without Mastoidectomy (CPT 69633)

Yes, tympanoplasty without mastoidectomy (CPT 69633) is medically necessary for this patient with right chronic otitis media, right conductive hearing loss, and ossicular chain reconstruction, even though no cholesteatoma was found intraoperatively.

Primary Justification

The procedure is clearly indicated based on the following:

• Conductive hearing loss documented (H90.11): The patient has unilateral right conductive hearing loss with unrestricted hearing on the contralateral side, which represents functionally significant hearing impairment requiring surgical correction 1

• Ossicular chain reconstruction performed: The operative note documents ossicular chain reconstruction using a Grace Partial Prosthesis, which falls under ossiculoplasty criteria when there is ossicular abnormality causing conductive hearing loss 1

• Chronic otitis media present (H66.91): The patient has documented right chronic otitis media requiring surgical intervention 2, 3

Evidence Supporting Tympanoplasty Without Mastoidectomy

Tympanoplasty alone (without mastoidectomy) is highly effective and appropriate for chronic otitis media without cholesteatoma:

• Multiple high-quality studies demonstrate that tympanoplasty without mastoidectomy achieves excellent outcomes in chronic otitis media patients, with graft success rates of 84.8-97% and significant hearing improvement 2, 3, 4

• A 2018 study showed mean hearing improvement from 46.9 dB to 29.4 dB postoperatively with tympanoplasty alone, even in patients with mastoid cavity opacification on imaging 2

• A 2019 prospective study confirmed that mastoidectomy is unnecessary for active mucosal chronic otitis media without cholesteatoma, with 90.5% graft uptake and 95.2% ear dryness achieved with tympanoplasty alone 3

• A 1997 analysis of 323 patients found no statistically significant difference in graft success rates between tympanoplasty with mastoidectomy (85.7%) versus without mastoidectomy (90.5%) for noncholesteatomatous chronic suppurative otitis media 4

Addressing the Cholesteatoma Diagnosis Code Discrepancy

Critical caveat: The diagnosis code H71.02 (cholesteatoma of attic, LEFT ear) appears to be a coding error, as:

• The operative note explicitly states "no cholesteatoma in the middle ear" and "no evidence of cholesteatoma" [@case documentation@]
• The surgery was performed on the RIGHT ear for right chronic otitis media
• This diagnosis code should be removed or corrected, as it does not reflect the actual surgical findings

Meeting MCG Criteria

The procedure meets MCG Ossiculoplasty criteria (ACG: A-0188):

• ✓ Conductive hearing loss that is functionally significant (documented right conductive hearing loss) 1
• ✓ Ossicular chain abnormality requiring reconstruction (ossicular chain reconstructed with prosthesis) [@case documentation@]
• ✓ Chronic otitis media requiring surgical intervention 2, 3

Quality of Life and Functional Outcomes

The procedure directly addresses morbidity and quality of life:

• Tympanoplasty significantly improves hearing in chronic otitis media with conductive hearing loss, with mean air-bone gap reduction from 25.7 dB to 10.3 dB 2
• Restoration of ossicular chain function optimizes auditory access and eliminates barriers to normal communication and daily functioning 5
• The procedure prevents ongoing complications of chronic otitis media including recurrent infections and progressive hearing deterioration 3, 4

Surgical Approach Appropriateness

Tympanoplasty without mastoidectomy is the appropriate surgical choice when:

• No cholesteatoma is present (confirmed intraoperatively in this case) 2, 3, 4
• The ear has been dry for an adequate period preoperatively 2
• Ossicular reconstruction is needed for conductive hearing loss 1
• Mastoid disease is not the primary pathology 3, 4

The decision to perform tympanoplasty without mastoidectomy is supported by current evidence showing equivalent or superior outcomes compared to combined procedures in non-cholesteatomatous chronic otitis media 2, 3, 4, 6.