Download Hearing Aids - Adult

HEARING AIDS - ADULT
HS-159
Easy Choice Health Plan, Inc.
Exactus Pharmacy Solutions, Inc.
Harmony Health Plan, Inc.
Missouri Care, Incorporated
WellCare Health Insurance of Arizona, Inc.,
operating in Hawai‘i as ‘Ohana Health Plan, Inc.
WellCare of Kentucky, Inc.
WellCare Health Plans of Kentucky, Inc.
WellCare Health Plans of New Jersey, Inc.
WellCare of Connecticut, Inc.
WellCare of Florida, Inc., operating in
Florida as Staywell
WellCare of Georgia, Inc.
WellCare of Louisiana, Inc.
Hearing Aids - Adult
WellCare of New York, Inc.
Policy Number: HS-159
WellCare of South Carolina, Inc.
WellCare of Texas, Inc.
WellCare Prescription Insurance, Inc.
Windsor Health Plan, Inc.
Original Effective Date: 3/18/2010
Revised Date(s): 3/18/2011; 3/1/2012;
3/7/2013; 3/6/2014; 3/5/2015; 3/3/2016
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.
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
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HEARING AIDS - ADULT
HS-159
DISCLAIMER
The Clinical Coverage Guideline (CCG) 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 CCG. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the
information contained in the CCG. Additionally, CCGs 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 CCG 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. All links are current at time of approval by the
Medical Policy Committee (MPC). Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com – select the
Provider tab, then “Tools” and “Clinical Guidelines”.
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
Applicable To:
Medicaid Medicare 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.
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
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HEARING AIDS - ADULT
HS-159
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Hearing aid fitting and dispensing.
Hearing aid repairs and accessories.
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 the recommendation 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 Georgia 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,
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, 20000 Hz.
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
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HEARING AIDS - ADULT
HS-159
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:
CPT Codes
92552
Pure Tone audiometry (threshold); air only
92555
Speech audiometry threshold
92556
Speech audiometry threshold; with speech recognition
92557
Comprehensive audiometry evaluation
92567
Tympanometry
92568
Acoustic reflex testing
92579
Visual reinforcement audiometry
92585
Auditory evoked potentials
92587
Evoked otoacoustic emissions
92588
Complete or diagnostic evaluation (comparison of transient or distortion product otoacoustic
emissions at multiple levels and frequency)
92541
92542
92543
92544
92545
92546
92547
Spontaneous nystagmus test
Positional nystagmus test
Caloric vestibular test
Optokinetic nystagmus test
Oscillating tracking test
Sinusodial vertical axis rotational testing
Use of vertical electrodes
HCPCS®* Level II Codes
V5095
Semi-implantable middle ear hearing prosthesis
V5170
Hearing aid, CROS, in the ear
V5180
Hearing aid, CROS, behind the ear
V5190
Hearing aid, CROS; glasses
V5210
Hearing aid, BICROS, in the ear
V5220
Hearing aid, BICROS, behind the ear V5230
Hearing aid, BICROS, glasses
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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.
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
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
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HEARING AIDS - ADULT
HS-159
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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
V5251
V5252
V5253
V5254
V5255
V5256
V5257
V5258
V5259
V5260
V5261
V5262
V5263
V5264
V5266
V5267
V5299
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
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
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
page 5
HEARING AIDS - ADULT
HS-159
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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:
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
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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.
CODING
See market specific criteria above for additional coding guidance.
CPT®* Codes – No applicable codes.
ICD-9-CM Procedure Codes – No applicable codes.
HCPCS ®* Level II Codes
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
V5100
Hearing aide, bilateral, body worn
V5120
Binaural; body
V5130
Binaural body; in the ear
V5140
Binaural body; behind the ear
V5150
Binaural, glasses
V5242
Hearing aid, analog ,monaural, cic (completely in the ear canal)
V5243
Hearing aid, analog, monaural, itc (in the canal)
V5244
Hearing aid, digitally programmable analog, monaural, CIC
V5245
Hearing aid, digitally programmable, analog, monaural, ITC
V5246
Hearing aid, digitally programmable analog, monaural, ITE (in the ear)
V5247
Hearing aid, digitally programmable analog, monaural, BTE (behind the ear)
V5248
Hearing aid, analog, binaural, CIC
V5249
Hearing aid, analog, binaural, ITC
V5250
Hearing aid, digitally programmable analog, binaural, CIC
V5251
Hearing aid, digitally programmable analog, binaural, ITC
V5252
Hearing aid, digitally programmable, binaural, ITE
V5253
Hearing aid, digitally programmable, binaural, BTE
V5254
Hearing aid, digital, monaural, CIC
V5255
Hearing aid, digital, monaural, ITC
V5256
Hearing aid, digital, monaural, ITE
V5257
Hearing aid, digital, monaural, BTE
V5258
Hearing aid, digital, binaural, CIC
V5259
Hearing aid, digital, binaural, ITC
V5260
Hearing aid, digital, binaural, ITE
V5261
Hearing aid, digital, binaural, BTE
V5262
Hearing aid, disposable, any type, monaural
V5263
Hearing aid, disposable, any type, binaural
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
page 6
HEARING AIDS - ADULT
HS-159
Non-Covered HCPCS Code
V5282
Assistive listening device, personal FM/DM system, any type
ICD-9-CM Diagnosis Codes
NOTE: Medical Necessity for hearing aids is based on the state-specific Medicaid guidelines outlined above.
389.00
389.01
389.02
389.03
389.04
389.05
389.06
389.08
389.10
389.11
389.12
389.13
389.14
389.15
389.16
389.17
389.18
389.20
389.21
389.22
389.7
389.8
744.00
744.01
744.02
744.03
744.04
744.05
744.09
744.23
744.24
744.3
Conductive hearing loss, unspecified
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
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
Specified congenital anomaly of Eustachian tube
Unspecified Anomaly of Ear [Congenital Anomaly or Congenital Deformity of Ear NOS] ICD-10-CM Diagnosis Codes
H90.0 - H90.8
Conductive and sensorineural hearing loss
H91.01 - H91.93
Other and unspecified hearing loss
H91.8x1 – H91.8X9 Other specified hearing loss
Q16.0 - Q16.9
Congenital malformations of ear causing impairment of hearing
Q17.2
Microtia
Q17.9
Congenital malformation of ear, unspecified
*Current Procedural Terminology (CPT) 2016 American Medical Association: Chicago, IL.®©
REFERENCES
1.
2.
3.
Agency for Health Care Administration. (2005, January). Florida Medicaid hearing services coverage and limitations handbook. Retrieved
from http://www.baccinc.org/medi/CD_April_2005/Provider_Handbooks/
Medicaid_Coverage_and_Limitations_Handbooks/Hearing_Services_Updated_January_2005.pdf
Part II: policies and procedures for orthotics and prosthetics and part III: hearing services. Georgia Department of Community Health Web
site. http://dch.georgia.gov/. Published January 1, 2016. Accessed February 29, 2016.
Handbook for providers of audiology services: chapter E-200 policy and procedures for audiology services. Illinois Department of
Healthcare and Family Services. http://www.illinois.gov/hfs/MedicalProviders/Handbooks/Pages/default.aspx. Published February 2016.
Clinical Coverage Guideline Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
page 7
HEARING AIDS - ADULT
HS-159
4.
5.
6.
Accessed February 29, 2016.
907 KAR 1:038: hearing and vision program services. Kentucky Legislative Research Commission Web site.
http://www.lrc.ky.gov/kar/907/001/038.htm. Accessed February 29, 2016.
KRS 334A.30: license required for speech-language pathology or audiology. Kentucky Legislative Research Commission Web site.
http://www.lrc.ky.gov/krs/334A00/030.PDF. Accessed February 29, 2016.
Hearing aid / audiology manual policy guidelines. New York State Medicaid Program Web site.
https://www.emedny.org/ProviderManuals/HearingAid/PDFS/HearingAid_Policy_Guidelines2007-1.pdf. Published February 2007.
Accessed February 29, 2016.
MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS
Date
Action
3/3/2016, 3/5/2015, 3/6/2014, 3/7/2013
3/1/2012


12/1/2011
3/18/2011
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Approved by MPC. Coding updates only.
Approved by MPC. Included updated information for FL Medicaid (per FL AHCA Summary of
Services) and OH Medicaid. Added GA and KY Medicaid requirements. No changes to IL, NY.
New template design approved by MPC.
Approved by MPC.
Clinical Coverage Guideline
Original Effective Date: 3/18/2010 - Revised:3/18/2011, 3/1/2012, 3/7/2013, 3/6/2014, 3/5/2015, 3/3/2016
page 8