BENEFIT COVERAGE GUIDELINE
Hearing Aids (Excludes Implantable Devices)
*Medicare has a policy.
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:
Hearing aids that are investigational include but are not limited to:
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.
Documentation must include ALL of the following information:
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 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)
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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.
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:
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 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)
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:
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:
Benefits for hearing aid repair/replacement services are often included in the hearing aid benefit limits or may not be covered. (See Scope)
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)
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.
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).