Skip to Main Content

Sunshine Health Covers Pediatric In-Office Ear Tube Procedures

Date: 06/18/25

Sunshine Health covers pediatric in-office ear tube procedures under local anesthesia when performed with a tympanostomy tube delivery device, such as the Hummingbird Tympanostomy Tube System.

Sunshine Health wants to make sure providers know that the health plan covers and process claims for this procedure, which is an option for treating children who have several middle ear infections, aka acute otitis media (AOM).

Ear tubes can also be used to treat buildup of fluid, or effusion, in the middle ear that has lasted more than three months.

Who can provide this treatment?

Ear, Nose, and Throat (ENT) surgeons can offer this option to families using a new add-on HCPCS code (+G0561), which was released by Centers for Medicare and Medicaid (CMS) on January 1, 2025.

What products are eligible for this treatment?

  • Sunshine Health Medicaid (MMA)
  • Comprehensive Long Term Care (LTC)
  • Children’s Medical Services (CMS) Health Plan
  • Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
  • Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
  • Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)

What providers need to know

  • CPT 69433 remains the underlying CPT code to identify tympanostomy (ear tube) procedures under local/topical anesthesia
  • Add-on HCPCS +G0561 was established by CMS to identify the incremental costs of performing in-office ear tube procedures for a pediatric population when performed with a tympanostomy tube delivery device.
  • Sunshine Health has configured HCPCS +G0561 and added +G0561 to Provider Fee Schedules to allow for proper processing
    • Providers can submit claims with +G0561 and receive claims payment when clinically appropriate.

Claims guidance

  • HCPCS +G0561 should be billed as a second-line item in addition to CPT 69433
  • When a procedure is performed bilaterally, providers should bill one unit and append the bilateral modifier (-50) to CPT 69433 and G0561

Sample claim form

Sample claim form 

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns:

SH_10217