Coverage for hearing aids, audiological testing and middle ear implants is determined according to individual or group customer benefits. The patient’s hearing aid benefit would be reviewed for details on examination, referral, and hearing aid dealer requirements.

Nonsurgical Treatment

Hearing Aids
Prescribed FDA-approved hearing aids are eligible for payment (per the FDA, hearing aids marketed for use by the general public should have FDA approval). However, the prescription for the hearing aid must accompany all claims submitted by hearing aid dealers/fitters. If the prescription is not submitted with the claim, the claim must be developed for that information.

Hearing aids should be reported with the code that most accurately describes the hearing aid selected. Use codes (V5030-V5080, V5100, V5120-V5150, V5170-V5190, V5210-V5230, V5242-V5263, V5298, V5299) as appropriate.

Surgical Treatment

Middle Ear Implant
Procedure codes S2230/V5095 should be used to report the implantation of a semi-implantable middle ear hearing prosthesis. Hearing implants and middle ear devices are classified as “hearing aids”.  Only when specifically requested by a group can the surgical implantation/removal of an implanted hearing device be identified as eligible within the group’s surgical benefit (since the hearing aid benefit is not intended to cover a surgical procedure).  When hearing impairment, as determined by a licensed physician, is of such magnitude as to require amplification, the patient’s medical record should support the medical necessity for amplification.

Prosthetic Hearing Devices

Bone Anchored Hearing Devices (BAHA)
Bone Anchored Hearing Devices (BAHA), code L8690, are covered as prosthetic devices, but only when indicated.  These are indicated when hearing aids are medically inappropriate, or cannot be used due to:

• Congenital or surgical malformations;
• Chronic disease of the ear canal, pinna or tympanic cavity
• Severe sensorineural hearing loss (pure tone air and bone conduction thresholds between 70 and 90 dBHL); or
• Surgery injury resulting in the cranial nerve VIII being severed or nonfunctioning.

Coverage for Prosthetics is determined according to individual or group customer benefits. The BAHA is appropriate for unilateral and/or bilateral hearing loss, when the above criteria have been met.  When the BAHA is eligible, the surgical implantation codes 69714 and 69715 are also eligible for reimbursement.  The use of the BAHA for any other indication than listed above will be denied as not medically necessary.   A participating, preferred, or network provider cannot bill the member for the non-covered service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Auditory Brainstem Implants
Auditory brainstem implants (L8614) are devices (e.g., Nucleus 24 Multichannel Auditory Brainstem Implant) that replace the function of the auditory nerve.  The device is implanted in the brainstem and provides electrical energy to the cochlear nerve to restore some hearing in individuals who have become deaf as a result of surgery to remove auditory nerve tumors.  The auditory brainstem implant is FDA approved for the treatment of hearing loss due to Neurofibromatosis Type II.  These patients require removal of cranial nerve VIII schwannoma.  The implant may be used for bilateral or unilateral cranial nerve VIII loss.

The receiver is implanted behind the ear. A wire leads from the receiver to a series of electrodes that are implanted into the brainstem. The speech processor and microphone/headset pick up sound and change it into electrical impulses that are sent to the implanted receiver.  The impulses travel down the wire to the electrodes, which electrically stimulate the area that normally receives signal from the ear.  Code S2235 should be used to report the implantation of this device.

Physicians should bill the appropriate services for implantation of the auditory brainstem device (L8614), using the codes for tumor resection (61520, 61530, 61598), if indicated, and also a code for the insertion for the auditory brainstem implant, code S2235. Use code 92640 for the diagnostic analysis with programming of the auditory brainstem implant. The use of the Auditory Brainstem Implants for any other condition than listed above will be denied as not medically necessary.  A participating, preferred, or network provider cannot bill the member for the non-covered service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Please reference Mountain State Medical Policy S-67 regarding cochlear implants.

Audiological Screening
Audiological testing performed without a physician evaluation and an order for the testing prior to testing are deemed to be screening in nature, and as such, is not covered. Hearing screening should be reported with procedure code V5008. The provider can bill the member for the denied service.

Audiological Testing
Audiological testing is eligible and should be reported under procedure codes 92550, 92553-92588 and 92620-92621, as appropriate. Please note that all of these services represent bilateral testing.

Routine Hearing Tests
Routine hearing tests, Screening Test, Pure Tone, Air Only (92551) and Pure Tone Audiometry Threshold, Air Only (92552) are eligible for members with coverage for preventive health services according to the preventive schedule published annually. 

Please reference Mountain State Medical Policy M-8 for Tympanometry and Acoustic Reflex Testing.

Aural Rehabilitation
Aural rehabilitation is frequently used as an integral component in the overall management of individuals with hearing loss.  It is often an interdisciplinary endeavor involving physicians, audiologists and speech-language pathologists.

Audiologists, under the direction of a physician or speech language pathologist, and speech-language pathologists certified by the American Speech-Language-Hearing Association (ASHA) are qualified to provide aural rehabilitation components.  The audiologist may be responsible for the fitting, dispensing and management of a hearing device, counseling the client about his or her hearing loss, the application of certain processes to enhance communication, and the skills training regarding environmental modifications which will facilitate the development of receptive and expressive communication.

An audiologist performs the primary evaluation (92626, 92627) of the status of an aural rehabilitation program under the direction of physicians or speech-language pathologists within their scope of practice.

The speech-language pathologist is typically responsible for evaluating the client’s receptive and expressive communication skills and providing the services to anchor improvement (92630-92633).  The speech-language pathologist also provides training and treatment for communication strategies, speech-perception training and auditory-visual-speech-perception training, speech and voice production and comprehension of oral, written and signed language.  There should be a plan for transitioning to a home program because maintenance therapy is not covered and is not medically necessary.  A participating, preferred, or network provider cannot bill the member for the non-covered service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Please reference Mountain State Medical Policy V-16 for Speech Therapy.

Aural rehabilitation, codes 92626-92633, is covered when it is a speech therapy benefit.

Please reference Mountain State Medical Policy Z-27 for eligible providers.

Description

Hearing impairment is a reduction in the ability to perceive sound. Hearing impairments can vary from slight to profound and are generally classified as conductive hearing loss, sensorineural hearing loss or mixed hearing loss.

Hearing loss can result from injury or disease of any part of the auditory system (e.g., foreign objects, growths, perforation). The type of hearing loss refers to the site of the lesion or pathology.

Conductive hearing loss results from impairment of sound transmission through the external or middle ear since these parts conduct mechanical vibrations to the inner ear or sensorineural system. Such loss may result from a perforated tympanic membrane, accumulation of pus, serous fluid in the middle ear (as in otitis media), or impaired ossicular mobility. In audiometric testing, a conductive loss is associated with better conduction thresholds in bone than in air, since bone conducted sound does not pass through the external or middle ear; whereas air conducted sound does.

Sensorineural hearing loss indicates a lesion in the inner ear, the eighth cranial nerve, or higher neural pathways. This type of hearing loss may result from Meniere's disease, viral labyrinthitis, tumors, multiple sclerosis or noise induced hearing loss.  Sensorineural hearing loss cannot be medically or surgically corrected.  It is a permanent loss.  It not only involves a reduction is sound level, or ability to hear faint sounds, but also affects speech discrimination or hearing acuity.

Mixed hearing loss results from a combined sensorineural-conductive dysfunction.

Hearing aids are instruments that amplify sound for individuals who are unable to hear well. Prior to determining treatment options, an audiological evaluation should be completed to determine the severity of the hearing loss as well as to determine the most appropriate treatment for the specific patient.

The following devices and procedures are available for treating these types of hearing loss:

Nonsurgical

Traditional Hearing Aids
Traditional hearing aids are externally worn microphones that amplify sound which is then directed to the ear through an ear mold that fits in the ear canal. These hearing aids can be defined as monaural, binaural, programmable, non-programmable, analog and digital.

Surgical

Middle Ear Implant
Middle ear implants (MEI) (e.g., Vibrant Soundbridge, The Direct System) are designed for individuals with moderate to severe sensorineural hearing loss who are dissatisfied with the limitations of conventional hearing aids. These devices, either implantable or semi-implantable, directly vibrate the ossicles of the inner ear to produce sound.

Please reference Mountain State Medical Policy S-67 for Cochlear Implants.

Please reference Mountain State Medical Policy S-52 for Post Operative Services Following Definitive Surgery.

Testing

Audiological Screening
These tests are done to identify persons (of any age) who have a hearing disorder, impairment and/or a disability that interferes with or has the potential for interfering with communication using a pass/fail criterion.  Testing is usually done by someone trained to perform pure tone supra-threshold (above threshold) testing usually at no more than 25 dB IL.  Universal newborn hearing tests are usually performed by automated systems by people trained to perform these specific tests. 

Hearing screening will only determine if there is the possibility of a hearing loss and whether or not hearing needs to be investigated further with a diagnostic test performed by an audiologist.  One example of an audiological screening test is the Pure Tone, Air Only Test.

Audiological Testing
These tests are done to determine the need for, or appropriate type of, medical and/or surgical treatment for a hearing deficit or related medical condition including differential diagnosis of diseases that are located in the eight nerve and brainstem, as well as cochlear diseases.

Assessment of hearing includes the administration and interpretation of behavioral, physioacoustic and electrophysiologic measures of the peripheral and central auditory systems.  Assessment of the vestibular system includes administration and interpretation of behavioral and electrophysiologic tests of equilibrium.  Assessment is accomplished by an audiologist or person supervised and trained by an audiologist using standardized testing procedures and appropriately calibrated instrumentation and leads to the diagnosis of hearing and/or vestibular abnormality to ensure proper treatment protocols.

The tests identify the existence, type and degree of hearing loss for each ear.  Upon completion of the basic audiologic assessment, the patient could be referred for further audiologic procedures/testing, aural rehabilitation, an audiologic rehabilitation evaluation including hearing aids or be recommended for routine follow-up.

Some examples of audiological testing are the Pure Tone Audiometry, Speech Audiometry, Acoustic Reflex Testing, Auditory Evoked Potentials, etc.

Routine Hearing Tests
Routine hearing tests is testing completed on a routine basis without specific complaints of increased hearing loss, tinnitus, dizziness, fullness or poor auditory perception.  They are also indicated when changes in the patient’s medical history report significant changes in hearing or balance symptoms which could alter the course of medical management of this condition.

Rehabilitation

Aural Rehabilitation
Aural rehabilitation is appropriate when individuals with hearing impairment are in need of services to facilitate communication (both receptive and expressive).  These services can include sensory aids, counseling, facilitation of effective strategies for communication, evaluating the acoustic environment surrounding the hearing impaired person, recommendations for functioning in difficult listening situations, promoting independence in communication and other referrals.

Aural rehabilitation is the process of identifying and diagnosing a hearing loss, providing different types of therapies to members who are hearing impaired, and implementing different amplification devices to aid the member’s hearing abilities.  Aural rehab includes specific procedures in which each therapy and amplification device has as its goal the habilitation or rehabilitation of persons to over the handicap/disability

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Not covered:  

• Routine hearing tests (except as indicated under Preventive care, children)


• Hearing aids (except as described below)


• Testing and examinations for the prescribing or fitting of hearing aids (except as needed for covered hearing aids described below)

FEP covers: 

• Hearing aids for children up to age 22, limited to $1,000 per ear per calendar year.


• Hearing aids for adults age 22 and over, limited to $1,000 per ear per 36-month period.


• Bone anchored hearing aids when medically necessary for members with traumatic injury or malformation of the external ear or middle ear (such as a surgically induced malformation or congenital malformation), limited to $1,000 per ear per calendar year.

NOTE:  Benefits for hearing aids are subject to the cost-sharing amounts shown in the brochure to the right under the "You Pay" columns.

CMS online manual pub.100-04, Chapter 12, Section 30.3

CMS online manual pub.100-02, Chapter 15, Section 80.3

American Speech-Language Hearing Association 1997-2009

Information and Resources – Hearing Tests.  WebMD  http://webmd,com/a-to-z-guides/hearing-tests

Ear, Nose and Throat Test and Procedures.  Cincinnati Children’s Hospital Medical Center, http://www.cincinnatichildrens.org/health/info/ent/procedure/hearing-tests.htm

Blue Cross Blue Shield Association Medical Policy Reference Manual 9.01.02

Blue Cross Blue Shield Association Medical Policy Reference Manual 7.01.03

Aural Rehabilitation.  Wikipedia Encyclopedia

Definition of and Competencies for Aural Rehabilitation.  American Speech-Language Hearing Association. Asha. (1984,May.) Vol. 26, pp.37-41.

Your Hearing Guide. 2009 Ceatus Media Group LLC. http://www.yourhearingguide.com/hearing-types.html.