BENEFIT COVERAGE GUIDELINE

COVERAGE GUIDELINE
CODING
RELATED POLICIES
SCOPE
ADDITIONAL INFORMATION
HISTORY

Hearing Aids (Excludes Implantable Devices)

Number 1.01.528*

Effective Date January 28, 2015

Revision Date(s) 01/13/15

Replaces N/A

*Medicare has a policy.

Coverage Guideline

NOTE: If benefits for a hearing aid are available, the following criteria apply. (See below for state mandate for Oregon members).

Hearing aids that are FDA-approved and dispensed by prescription may be considered medically necessary for a moderate hearing loss of 40 to 60 dB (based on pure tone average bone-conduction detection threshold) for any of the following:

  • Conductive hearing loss (external and middle ear blockage/damage/disease) that is unresponsive to medical/surgical interventions OR
  • Sensorineural hearing loss (inner ear cilia are damaged) OR
  • Mixed hearing loss (combination of conduction hearing loss and sensorineural hearing loss)

Hearing aids that are investigational include but are not limited to:

  • Non-implantable intraoral (in the mouth) bone conduction hearing aids (e.g., SoundBite™ Hearing System)

Over-the-counter hearing assistive devices/sound amplifiers available without a prescription are not covered (e.g. NewEar™, Pocketalker®, TV Ears® and others).

NOTE: This policy does not address semi-implantable/fully-implantable or bone anchored hearing devices (see Related Policies/Guidelines).

Traditional hearing aids are externally worn microphones that amplify sound to the ear through an ear mold that fits in the ear canal. (See Definition of Terms below)

Selection of the hearing aid is based on the results from a complete work-up performed by a hearing professional that includes skilled hearing tests and assessment along with fitting the chosen device.

The hearing aid dispensed should meet the hearing requirements of the member in the environments and under the conditions where enhanced hearing is needed.

Required Documentation

Documentation must include ALL of the following information:

  • Written prescription from the examining physician/licensed healthcare provider within the past 6 months
  • A complete audiology evaluation within the past 6 month
  • Explanation of audiometric test data/results that demonstrates the member’s hearing loss & need for a hearing aid
  • History of prior use or current use of a hearing aid (not applicable if the member has never had a hearing aid)
  • Recommendation for the type of hearing aid technology that is appropriate for the member
  • Follow up plan for assessing the effectiveness/outcome of using a hearing aid - A trial period may be needed to test the usability of a specific hearing aid model/type.

Definition of Terms

  • Audiometric testing: Diagnostic tests that evaluate the ability to hear sounds. The intensity (loudness) of sound is measured in decibels. The tone (speed of sound wave vibrations) is measured in cycles per second. The standard battery of hearing tests varies depending on whether the patient is an infant, child or adult.
  • Hearing impairment (deafness/hearing loss): A reduction in the ability to perceive sound that is classified as mild, moderate, severe or profound.
  • Pure tone average (PTA): Average air conduction threshold measured with an earphone.
  • Traditional hearing aid: A non-implanted, non-disposable on-ear or in-ear device that is FDA-approved and dispensed only by prescription.

Exclusions and Limitations

Hearing aids are specifically excluded under many benefit plans. (See Scope)

When hearing aid benefits exist in a health plan, limitations may include a dollar maximum and/or frequency of benefit availability (e.g. once every 36 months or once every 48 months).

Oregon

Oregon has a specific statute that mandates a benefit level of coverage set by the state and adjusted annually for one nondisposable hearing aid per hearing impaired ear for covered members who are 18 years of age or younger OR 19 to 25 years of age and enrolled in a secondary school or an accredited educational institution. More information regarding covered and non-covered services and other administrative criteria for dispensing hearing aids and the frequency of replacements can be found at the following link: https://www.oregonlegislature.gov/bills_laws/lawsstatutes/2013ors743A.html. (See section 743A.141 Hearing Aids). Accessed December, 2014. (5) (See Scope)

Coding

Add any descriptive text here. Copy/Paste to create additional categories below.

CPT

Number

Description

92550

Tympanometry and reflex threshold measurements

92551

Screening test, pure tone, air only

92552

Pure tone audiometry (threshold); air only

92553

Pure tone audiometry (threshold); air and bone

92555

Speech audiometry threshold;

92556

Speech audiometry threshold; with speech recognition

0208T

Pure tone audiometry (threshold), automated; air only

0209T

Pure tone audiometry (threshold), automated; air and bone

0210T

Speech audiometry threshold, automated;

0211T

Speech audiometry threshold, automated; with speech recognition

0212T

Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated

HCPCS

Number

Description

V5014

Repair/modification of a hearing aid

V5030

Hearing aid, monaural, body worn, air conduction

V5040

Hearing aid, monaural, body worn, bone conduction

V5050

Hearing aid, monaural, in the ear

V5060

Hearing aid, monaural, behind the ear

V5120-V5267

Hearing aids, services and accessories

V5298

Hearing aid, not otherwise classified

V7212

Encounter for hearing conservation and treatment

Related Guidelines / Policies

7.01.05

Cochlear Implant

7.01.84

Semi-Implantable and Fully Implantable Middle Ear Hearing Aids

7.01.547

Implantable Bone Conduction and Bone-Anchored Hearing Aids

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Additional Information

Background

This policy was created in March 2014. Since that time, the policy has been reviewed on a regular basis and updated as needed. The most recent review was performed through December 2014.

Hearing loss is described as conductive, sensorineural, or mixed, and can be unilateral or bilateral. The American Speech - Language - Hearing Association (ASHA) has defined the degree of hearing loss based on pure-tone average (PTA). The PTA is the average air-conduction threshold for 1000 and 2000 Hz, and 3000 Hz measured with an earphone. Normal hearing is the detection of sound at or below 20 decibels (dB). (1)

The degree of hearing loss based on PTA detection thresholds is defined as:

  • Mild hearing loss (20 to 40 dB)
  • Moderate hearing loss (40 to 60 dB)
  • Severe hearing loss (60 to 80 dB)
  • Profound hearing loss (greater or equal to 80 dB)

Hearing Instrument/Aids

A hearing aid is an electronic device used to help members with a hearing impairment by providing sound amplification through the use of a microphone, amplifier and receiver. Members with moderate to severe sensorineural hearing loss are usually fit with acoustic hearing aids that are worn externally. An air-conduction (AC) hearing aid can benefit members with sensorineural, conductive, or mixed hearing loss. Contralateral routing of signal (CROS) is a system in which a microphone on the affected side transmits a signal to an air-conduction hearing aid on the normal or less affected side. (2) Hearing aids that are marketed for use by the general public should have approval from the U.S. Food and Drug Administration (FDA).

Hearing Aid Styles

There are two hearing aid styles. (3)

  • The body level instrument/aid (worn on the body) is not commonly prescribed and yet may be used for patients, including infants, whose ears are too small to hold a behind the ear aid.
  • The ear level instrument/aid (worn on and/or in the ear) is categorized by where on the ear the device is worn:
  • Behind the ear (BTE)
  • Completely in the canal (CIC)
  • In the canal (ITC)
  • In the ear (ITE)

The receiver that fits in the ear canal for all hearing aids requires a mold and is custom-fitted to the patient.

Hearing Aid Types

There are three types of hearing aids.(3)

  • Analog hearing aids convert sound waves that are amplified as an electrical signal in proportion to the sound signal. Though it has few adjustment options for the audiologist to fine-tine the instrument to meet the member’s amplification needs. Analog aids are a relatively inexpensive option. However, analog hearing aids are being replaced by digital technology.
  • Digital hearing aids convert sound waves into numerical codes before amplifying them, similar to binary computer code. This technology is more flexible with options for fine tuning the hearing aid to the member’s hearing needs by the audiologist and user.
  • Digital hybrid hearing aids have both analog technology for sound processing and digital technology for programming. Hybrid aids offer more options for the audiologist and user to adjust the “channels” to meet a variety of listening environments.

Accessories

Adapters for telephones are not covered.

Batteries and cords often are not covered.

Benefits for the following are often included in the hearing aid benefit limits or may not be covered:

  • Ear molds
  • Hearing aid dispensing fees
  • Hearing aid fittings

Over-the-Counter Hearing/Listening Assistive Devices

Over-the-counter hearing assistive devices/sound amplifiers available without a prescription are not covered. These include but are not limited to the following:

  • NewEar™
  • Pocketalker®
  • TV Ears®

Repair/Replacement

Benefits for hearing aid repair/replacement services are often included in the hearing aid benefit limits or may not be covered. (See Scope)

Regulatory Status

Air conduction hearing aids that are intended to compensate for hearing loss, are regulated by the U.S. Food and Drug Administration (FDA). The FDA does not consider sound amplifiers to be medical devices when labeled for recreational or other use by individuals with normal hearing. However, certain safety regulations related to sound output levels still apply to these products. (4)

Medicare National Coverage

Hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded from coverage. (6)

References

  1. American Speech-Language-Hearing Association (1988). Determining threshold level for speech [guidelines]. Available online at: http://www.asha.org/policy/GL1988-00008.htm. Last accessed December, 2014.
  2. National Institute on Deafness and Other Communication Disorders (NIDCD). Hearing Aids, NIH Pub. No. 13-4340. Reviewed September 2013. Available online at: http://www.nidcd.nih.gov/health/hearing/pages/hearingaid.aspx. Last accessed December, 2014.
  3. Yetter C. A hearing aid primer. WROCC outreach site at Western Oregon University. Available online at: http://www.wou.edu/education/sped/wrocc/training_materials_page.htm. Last accessed January 2, 2015.
  4. U.S. Food and Drug Administration. Home health and consumer devices. Hearing aids. Last updated 06/11/14. Available online at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/HearingAids/default.htm. Accessed December, 2014.
  5. Oregon State Legislature/Oregon State Statutes Chapter 743A Health insurance: Required reimbursement. Available at URL address: https://www.oregonlegislature.gov/bills_laws/lawsstatutes/2013ors743A.html. Section 743A.141 Hearing Aids. Accessed December, 2014.
  6. Medicare Policy Benefit Manual. Chapter 16 - General Exclusions from Coverage. Available online at: http://www.cms.gov/manuals/Downloads/bp102c16.pdf . Accessed December, 2014.

History

Date

Reason

03/10/14

New policy. Non-implanted traditional hearing aids that are FDA-approved and dispensed by prescription may be considered medically necessary for a moderate hearing loss when criteria are met.

01/28/15

Annual Review. Policy reviewed. Added Definition of Terms to Policy Guidelines. Benefit Application now includes reference and hyperlink to Oregon specific laws about coverage of non-implantable, non-disposable hearing aids. Reference 5 added; others renumbered. Policy statement unchanged. ICD-9 and ICD-10 codes removed from policy; these are not utilized in adjudication of the policy.

   


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
©2015 Premera All Rights Reserved.