Hearing Aids - Adult HEARING AIDS - ADULT HS-159. Policy Number: HS-159. Original Effective Date: 3/18/2010. Revised Date(s): 3/18/2011; 3/1/2012

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1 Harmony Behavioral Health, Inc. Harmony Behavioral Health of Florida, Inc. Harmony Health Plan of Illinois, Inc. HealthEase of Florida, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Insurance of New York, Inc. WellCare Health Plans of New Jersey, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of Ohio, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Hearing Aids - Adult Policy Number: Original Effective Date: 3/18/2010 Revised Date(s): 3/18/2011; 3/1/2012 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

2 BACKGROUND Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear. A hearing aid consists of a microphone, amplifier and receiver. POSITION STATEMENT Note: For Bone Anchored Hearing Aids, refer to the guideline HS-045 Bone Anchored Hearing Aid (Baha ). General Criteria Set (Medicare and all markets not listed below) Monaural Hearing Aid Monaural hearing aids for adults are considered medically necessary if the following criteria are met: Hearing loss in the better ear of 30dBHL or greater (from ANSI, 1969) for the pure tone average of 500, 1000 and 2000 Hz, or, a spondee threshold in the better ear of 30 dbhl or greater when pure tone thresholds cannot be established; AND, Hearing loss in each ear is less than 30 dbhl at the frequencies below 2000 Hz and thresholds in each ear are greater than 40 dbhl at 2000 Hz and higher; AND, Documentation of communication need and a statement that the member is alert and oriented and able to utilize the aid appropriately. Binaural Hearing Aid Same as the criteria for monaural hearing aid PLUS one of the following: Significant social, vocational or educational demands; OR, Previous user of binaural hearing aids; OR, Significant visual impairment The following criteria sets are based on state-specific Medicaid guidelines from Florida, Georgia, Illinois, Kentucky, New York and Ohio and supersede the above general criteria. FLORIDA MEDICAID Hearing aids are considered medically necessary if the following criteria are met; Hearing loss is bilateral; AND, An average hearing loss level of 40 dbhl or greater (ANSI standards) for 500, 1000, and 2000 Hz by pure tone air conduction, or the difference between level 1000 Hz and 2000 Hz is 20 dbhl or more, while the average of the air conduction level (ANSI standards) at 500 and 1000 Hz is 30 dbhl or greater. Medicaid reimburses for hearing services rendered by licensed, Medicaid-participating otolaryngologists, otologists, audiologists, and hearing aid specialists. Medicaid reimbursable hearing services include: Cochlear implant services. Diagnostic audiological testing. Hearing aid fitting and dispensing. Hearing aid repairs and accessories. Clinical Coverage Guideline page 2

3 Hearing aids. Hearing evaluations to determine hearing aid candidacy. Mandatory newborn hearing screening. Medicaid reimbursement for hearing services includes the following limitations: Medicaid reimbursement is limited to one evaluation for the purpose of determining hearing aid candidacy, per recipient, every three years from the date of the last evaluation. Date of service for hearing aids is the date the hearing aid is ordered - provider cannot claim reimbursement until the recipient receives the hearing aid(s). Hearing aids are limited to one per ear, per recipient, every three years. Cochlear implants are limited to one in either ear, but not both. Cochlear implant surgery must be prior authorized. Medicaid does not reimburse for routine maintenance, batteries, cord or wire replacement, or cleaning. Medicaid does not reimburse for repairs until after the manufacturer s warranty has expired. The provider may request prior authorization for reimbursement for services in excess of the service limitations. Medicaid reimburses for hearing services for all Medicaid recipients, according to medical necessity and hearing loss criteria. Medicaid reimbursement for hearing services is the maximum Medicaid fee or the provider s customary fee, whichever is less. GEORGIA MEDICAID Hearing aid criteria includes: medical consultation and recommendation by a licensed physician specializing in ears, nose and throat (ENT), prescribing hearing aids and/or an audiogram. The consultation report or CMN must document the member s medical diagnosis and condition supporting therecommendation for hearing aid(s); an audiological examination (audiogram) by a licensed audiologist that supports the recommendation for an ENT consultation and the hearing aid(s); it is the responsibility of the GA licensed audiologist to determine the appropriate hearing aid device through assessment and to recommend the appropriate hearing aid device; only a GA licensed audiologist is allowed to evaluate, fit, and dispense the hearing aid(s) for children age three (3) and under. Note: For specific coverage of hearing aids and equipment, refer to Appendix E of Part II: Policies and Procedures for Orthotics and Prosthetics and Part III: Hearing Services (Georgia Department of Community Health Division of Medical Assistance, 2010). ILLINOIS MEDICAID Monaural hearing aids are considered medically necessary if the following criteria are met: In an acoustically treated sound suite Hearing loss must be 20 dbs or greater at any two of the following frequencies: 500, 1000, 2000, 4000, Clinical Coverage Guideline page 3

4 8000 Hz; OR, Hearing loss must be 25 db or greater at any one of the 500, 1000, 2000 Hz. In other than an acoustically treated sound suite Hearing loss must be 30 db or greater at any one of 500, 1000, 2000, 4000, 8000 Hz; OR, Hearing loss must be 35 db or greater at any one of 500, 1000, Hz. KENTUCKY MEDICAID All hearing coverage shall be: Limited to an individual under age twenty-one (21); and Provided in accordance with the Hearing Program Manual for the State of Kentucky. Unless a recipient's health care provider demonstrates that services in excess of the limitations established in this subsection are medically necessary, reimbursement for services provided by an audiologist (licensed pursuant to KRS 334A.030) to a recipient shall be limited to: The following procedures: Code Procedure Pure Tone audiometry (threshold); air only Speech audiometry threshold Speech audiometry threshold; with speech recognition Comprehensive audiometry evaluation Tympanometry Acoustic reflex testing Visual reinforcement audiometry Auditory evoked potentials Evoked otoacoustic emissions Complete or diagnostic evaluation (comparison of transient or distortion product otoacoustic emissions at multiple levels and frequency) Spontaneous nystagmus test Positional nystagmus test Caloric vestibular test Optokinetic nystagmus test Oscillating tracking test Sinusodial vertical axis rotational testing Use of vertical electrodes A complete hearing evaluation; Hearing instrument evaluation; Three (3) follow-up visits that shall be: o Within the six (6) month period immediately following fitting of a hearing instrument; and o Related to the proper fit and adjustment of the hearing instrument; and One (1) additional follow-up visit that is: o At least six (6) months following the fitting of the hearing instrument; and o Related to the proper fit and adjustment of the hearing instrument. Clinical Coverage Guideline page 4

5 One (1) additional follow-up visit that is: Hearing instrument benefit coverage shall: Be for a hearing instrument model that is: o Recommended by an audiologist licensed pursuant to KRS 334A.030; o Available through a Medicaid-participating specialist in hearing instruments; Not exceed $800 per ear every thirty-six (36) months; and Be limited to the following procedures: Code V5010 V5011 V5014 V5015 V5020 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5095 V5100 V5120 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210 V5220 V5230 V5240 V5241 V5242 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 Procedure Assessment for Hearing instrument Fitting, Orientation, Checking of Hearing instrument Repair, Modification of Hearing Instrument Hearing Instrument Repair Professional Fee Conformity Evaluation Hearing Instrument, Monaural, Body Aid Conduction Hearing Instrument, Monaural, Body Worn, Bone Conduction Hearing Instrument, Monaural, In the Ear Hearing Hearing Instrument, Monaural, Behind the Ear Hearing Glasses; Air Conduction Glasses; Bone Conduction Dispensing Fee, Unspecified Hearing Instrument Semi-Implantable Middle Ear Hearing Prosthesis Hearing Instrument, Bilateral, Body Worn Binaural; Body Binaural; In the Ear Binaural; Behind the Ear Binaural; Glasses Dispensing Fee, Binaural Hearing Instrument, Cros, In the Ear Hearing Instrument, Cros, Behind the Ear Hearing Instrument, Cros, Glasses Dispensing Fee, Cros Hearing Instrument, Bicros, In the Ear Hearing Instrument, Bicros, Behind the Ear Hearing Instrument, Bicros, Glasses Dispensing Fee, Bicros Dispensing Fee, Monaural Hearing Instrument, Any Type Hearing Instrument, Analog, Monaural, CIC (Completely In the Ear Canal) Hearing Instrument, Analog, Monaural, ITC (In the Canal) Hearing Instrument, Digitally Programmable Analog, Monaural, CIC Hearing Instrument, Digitally Programmable Analog, Monaural, ITC Hearing Instrument, Digitally Programmable Analog, Monaural, ITE (In the Ear) Hearing Instrument, Digitally Programmable Analog, Monaural, BTE (Behind the Ear) Hearing Instrument, Analog, Binaural, CIC Hearing Instrument, Analog, Binaural, ITC Hearing Instrument, Digitally Programmable Analog, Binaural, CIC Clinical Coverage Guideline page 5

6 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 V5264 V5266 V5267 V5299 Hearing Instrument, Digitally Programmable Analog, Binaural, ITC Hearing Instrument, Digitally Programmable, Binaural, ITE Hearing Instrument, Digitally Programmable, Binaural, BTE Hearing Instrument, Digital, Monaural, CIC Hearing Instrument, Digital, Monaural, ITC Hearing Instrument, Digital, Monaural, ITE Hearing Instrument, Digital, Monaural, BTE Hearing Instrument, Digital, Binaural, CIC Hearing Instrument, Digital, Binaural, ITC Hearing Instrument, Digital, Binaural, ITE Hearing Instrument, Digital, Binaural, BTE Hearing Instrument, Disposable, Any Type, Monaural Hearing Instrument, Disposable, Any Type, Binaural Ear Mold (One (1) Ear Mold Per Year Per Ear and if Medically Necessary) Hearing Instrument Battery (Limit of Four (4) Per Instrument When Billed With A New Hearing Instrument Or A Replacement Instrument) Hearing Instrument Supplies, Accessories Hearing Service Miscellaneous (May Be Used to Bill Warranty Replacement Hearing Instruments But Shall be Covered Only if Prior Authorized by the Department) NEW YORK MEDICAID Monaural Hearing Aid Monaural hearing aids for adults are considered medically necessary if the following criteria are met: Hearing loss in the better ear of 30dBHL or greater (from ANSI, 1969) for the pure tone average of 500, 1000 and 2000 Hz, or, a spondee threshold in the better ear of 30 dbhl or greater when pure tone thresholds cannot be established; AND, Hearing loss in each ear is less than 30 dbhl at the frequencies below 2000 Hz and thresholds in each ear are greater than 40 dbhl at 2000 Hz and higher; AND, Documentation of communication need and a statement that the member is alert and oriented and able to utilize the aid appropriately. Binaural Hearing Aid Same as the criteria for monaural hearing aid PLUS one of the following: Significant social, vocational or educational demands; OR, Previous user of binaural hearing aids; OR, Significant visual impairment FM systems are considered NOT medically necessary and are NOT a covered benefit. OHIO MEDICAID Hearing tests should, at a minimum, contain ALL of the following elements for members 21 years of age and Clinical Coverage Guideline page 6

7 older: At least four thresholds for air conducted stimuli of 500, 1000, 2000 and 4000 Hz; AND, Air conducted speech awareness, or speech reception threshold; AND, Most comfortable and uncomfortable listening level; AND, Bilateral tests should be performed (If a bilateral test cannot be performed a letter stating the reason should be included; AND Bone-conducted pure-tone evaluation, unless the consumer s cognitive abilities do not permit such testing. Hearing test results shall be obtained bilaterally unless the recipient s behavior/condition does not permit bilateral evaluation. If bilateral testing cannot be done, supporting documentation regarding this issue must be provided. All tests shall be performed in an appropriate sound environment in accordance with the standards accepted by the American national standards institute (ANSI S , R2003). (New item in the updated contract). Note: Evaluation of results for consumers twenty-one years or older must show a best pure-tone average of thirty-one db HL or greater and in conjunction with the remainder of the hearing evaluation, results that demonstrate the need for a hearing aid. If physical or developmental limitations preclude these evaluation results an explanation and alternative evaluation results must be provided. Hearing tests for consumers age 20 years or younger shall include, at a minimum, all of the following for a basic hearing test: At least four thresholds for air conducted stimuli of five hundred Hz, one thousand Hz, two thousand Hz, and four thousand Hz; AND Air conducted speech awareness, or speech reception threshold; AND Most comfortable and uncomfortable listening level; AND Bone-conducted pure-tone evaluation, unless the consumer s cognitive abilities do not permit such testing; AND Tympanometry; AND Acoustic reflex battery; AND Otoacoustic emissions testing. NOTE: Hearing test results for consumers aged twenty years or younger must show a best pure-tone average of twenty six db HL or greater and when interpreted in conjunction with the remainder of the hearing test results that constitute a basic hearing test must demonstrate the need for a hearing aid. If physical or developmental limitations preclude these evaluation results, an explanation and alternative evaluation results must be provided. Hearing test results for consumers aged twenty years or younger are valid for prior authorization purposes only if the testing was conducted by a provider authorized to perform the complete battery of hearing tests that are listed in paragraph (C)(3) of this rule as part of their respective scope of practice. The following types of hearing aids are not covered by Ohio Medicaid: All types of in the canal and completely in the canal hearing aids; All types of disposable hearing aids; Used or reconditioned hearing aids, which are defined as hearing aids that have been previously utilized by another individual; and Digital and programmable hearing aids for adults twenty-one years or older. Hearing aids are considered medically necessary if the evaluation of test results indicate the following: A pure-tone average of 31 dbhl or greater at the Hz- levels stated above Hearing test results shall be obtained bilaterally unless the recipient s behavior/condition does not permit bilateral testing. If bilateral testing cannot be done, supporting documentation regarding this issue must be provided. All tests shall be performed in an appropriate sound environment in accordance with the standards accepted by the (ANSI S , R2003). Clinical Coverage Guideline page 7

8 Conventional Hearing Aids Adults twenty one years or older are eligible for conventional hearing aids only. Hearing evaluation results must clearly demonstrate the need for a hearing aid. Programmable and Digital Hearing Aids Programmable and digital hearing aids are only eligible for reimbursement if the consumer is twenty years of age or younger and a programmable and digital hearing aid is medically necessary. Hearing evaluation results must clearly demonstrate the need for a hearing aid. Binaural hearing aids, CROS, and BiCROS aids are not routinely covered by the medicaid program but may be authorized for persons with special documented needs; e.g., child for whom binaural hearing is necessary for development of speech. Each consumer of a hearing aid shall be scheduled for a recheck to assess the performance and consumer acceptability of the aid within thirty days of receipt of the aid by the consumer. A copy of the recheck report, countersigned by the consumer or an explanation of why the recheck was not performed, shall be maintained in the provider s file for a period of four years. No claim for payment should be made prior to a recheck or thirty days from the initial fitting of the aid, whichever comes first. When a recheck is performed within thirty days and the hearing aid is deemed unacceptable by both the hearing aid provider and the consumer, the cost of the earmold, batteries, and one month s use of the instrument will be borne by the ODJFS. On the rare occasions that this may happen, the original authorization form must be forwarded to ODJFS for cancellation and subsequent issuance of a revised authorization reflecting the new cost. If payment has been made on the original authorization, no adjustment to payment will be authorized. CODING CPT * Codes - No applicable codes ICD-9-CM Procedure Codes - No applicable Codes HCPCS * Level II Codes V5030 V5040 V5050 V5060 V5095 V5100 V5120 V5130 V5140 V5150 V5170 V5180 V5190 V5210 V5220 V5230 V5242 Hearing aid, monaural; body worn, air conduction Hearing aid, monaural; body worn, bone conduction Hearing aid, monaural; in the ear Hearing aid, monaural; behind the ear Semi-implantable middle ear hearing prosthesis Hearing aide, bilateral, body worn Binaural; body Binaural body; in the ear Binaural body; behind the ear Binaural, glasses Hearing aid, CROS, in the ear Hearing aid, CROS, behind the ear Hearing aid, CROS; glasses Hearing aid, BICROS, in the ear Hearing aid, BICROS, behind the ear Hearing aid, BICROS, glasses Hearing aid, analog,monaural, cic (completely in the ear canal) Clinical Coverage Guideline page 8

9 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 Hearing aid, analog, monaural, itc (in the canal) Hearing aid, digitally programmable analog, monaural, CIC Hearing aid, digitally programmable, analog, monaural, ITC Hearing aid, digitally programmable analog, monaural, ITE (in the ear) Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) Hearing aid, analog, binaural, CIC Hearing aid, analog, binaural, ITC Hearing aid, digitally programmable analog, binaural, CIC Hearing aid, digitally programmable analog, binaural, ITC Hearing aid, digitally programmable, binaural, ITE Hearing aid, digitally programmable, binaural, BTE Hearing aid, digital, monaural, CIC Hearing aid, digital, monaural, ITC Hearing aid, digital, monaural, ITE Hearing aid, digital, monaural, BTE Hearing aid, digital, binaural, CIC Hearing aid, digital, binaural, ITC Hearing aid, digital, binaural, ITE Hearing aid, digital, binaural, BTE Hearing aid, disposable, any type, monaural Hearing aid, disposable, any type, binaural ICD-9-CM Diagnosis Codes NOTE: Medical Necessity for hearing aids is based on the state-specific Medicaid guidelines outlined above Conductive Hearing Loss, External Ear Conductive Hearing Loss, Tympanic Membrane Conductive Hearing Loss, Middle Ear Conductive Hearing Loss, Inner Ear Conductive Hearing Loss, Unilateral Conductive Hearing Loss, Bilateral Conductive Hearing Loss of Combined Types Sensorineural Hearing Loss, Unspecified Sensory Hearing Loss, Bilateral Neural Hearing Loss, Bilateral Neural Hearing Loss, Unilateral Central Hearing Loss Sensorineural Hearing Loss, Unilateral Sensorineural Hearing Loss, Asymmetrical Sensory Hearing Loss, Unilateral Sensorineural Hearing Loss, Bilateral Mixed Hearing Loss [Mixed Conductive and Sensorineural], Unspecified Mixed Hearing Loss [Mixed Conductive and Sensorineural], Unilateral Mixed Hearing Loss [Mixed Conductive and Sensorineural], Bilateral Deaf, Nonspeaking, Not Elsewhere Classifiable Other Specified Forms of Hearing Loss Unspecified Congenital Anomaly of Ear, Causing Impairment of Hearing Congenital Absence of External Ear, Causing Impairment of Hearing Other Congenital Anomaly of External Ear, Causing Impairment of Hearing Congenital Anomaly of Middle Ear, except Ossicles, Causing Impairment of Hearing Clinical Coverage Guideline page 9

10 Congenital Anomalies of Ear Ossicles, Causing Impairment of Hearing Anomalies of Inner Ear, Causing Impairment of Hearing Other Anomalies of Ear, Causing Impairment of Hearing Microtia Unspecified Anomaly of Ear [Congenital Anomaly or Congenital Deformity of Ear NOS] *Current Procedural Terminology (CPT) 2012 American Medical Association: Chicago, IL. REFERENCES Government Agencies, Professional and Medical Organizations 1. Florida Agency for Health Care Administration. (2011). Florida Medicaid summary of services. Retrieved from 2. Agency for Health Care Administration. (2005, January). Florida Medicaid hearing services coverage and limitations handbook. Retrieved from Medicaid_Coverage_and_Limitations_Handbooks/Hearing_Services_Updated_January_2005.pdf 3. Georgia Department of Community Health Division of Medical Assistance. (2010, January 1). Part II: policies and procedures for orthotics and prosthetics and part III: hearing services. Retrieved from 4. Illinois Department of Public Aid. (2003, March). Handbook for providers of audiology services: chapter E-200 policy and procedures for audiology services. Retrieved from 5. Kentucky Legislative Research Commission. (2011). Kentucky Administrative Regulation 907 KAR 1:038: hearing and vision program services. Retrieved February 29, 2012 from 6. Kentucky Legislative Research Commission. (2011). Kentucky Revised Statuses KRS 334A.30: license required for speech-language pathology or audiology. Retrieved on February 29, 2012 from 7. New York State Medicaid Program. (2007, February 1). Hearing aid / audiology manual policy guidelines. Retrieved from https://www.emedny.org/providermanuals/hearingaid/pdfs/hearingaid_policy_ Guidelines pdf 8. Ohio Administrative Code. (2010, September 1). Division of medical assistance: chapter 5101: hearing aids. Retrieved from HISTORY AND REVISIONS Date Action 3/1/2012 Approved by MPC. Included updated information for Florida Medicaid (per FL AHCA Summary of Services) and Ohio Medicaid. Added Georgia and Kentucky Medicaid requirements. No changes to Illinois or New York. 12/1/2011 New template design approved by MPC. 3/18/2011 Approved by MPC. Clinical Coverage Guideline page 10

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