Download Evaluation of Hearing Impairment

Evaluation of Hearing Impairment
Corporate Medical Policy
File name: Evaluation of Hearing Impairment
File code: UM.DIAG.01
Origination: 07/1997
Last Review: 01/2016
Next Review: 01/2017
Effective Date: 01/01/2016
Description
Hearing impairment or hearing loss is a reduction in the ability to perceive sound. The
loss may range from slight to complete deafness. Audiometric studies are diagnostic
tests that evaluate sensorineural and conductive hearing losses. Conductive hearing
loss is the result of disorders of the external or middle ear; sensory hearing loss is
secondary to disturbance of the cochlea; neural hearing loss results from disease of
the auditory (eighth) nerve or central auditory channel connections. Sensory and
neural hearing losses are frequently included under the term sensorineural hearing
loss. Mixed or combined hearing loss involves disturbances of both conductive and
sensorineural mechanisms.
Policy
Coding Information
Click the links below for attachments, coding tables & instructions.
Attachment I- CPT coding table & instructions
Attachment II- ICD-10 coding table
When a service may be considered medically necessary:
The Plan covers a screening test for hearing in conjunction with a preventive medicine
evaluation and management service when done in accordance with current American
Academy of Pediatrics, American Academy of Family Practice, and/or Bright Futures
guidelines.
Audiometric studies may be medically necessary in illnesses or injuries including, but
not limited to, the following:
• Hearing loss;
• Otitis media;
• Meniere’s disease;
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Medical Policy Number: UM.DIAG.01
•
•
•
•
•
•
•
•
•
•
•
•
•
Labyrinthitis;
Vertigo (dizziness);
Tinnitus;
Cochlear otosclerosis;
Neoplasms of the auditory or central nervous system;
Congenital anomalies;
Surgery involving the auditory and/or central nervous system, e.g., skull-based
tumors such as acoustic neuroma and meningioma;
Facial nerve paralysis (Bell’s palsy);
Bacterial meningitis;
Exposure to intense noise;
Ototoxic drugs;
Fractures of the temporal bone or trauma affecting the central auditory
pathways.
Family history of childhood hearing loss due to a genetically inheritable condition
The grid that follows identifies standard and specialized audiology tests for adults,
children, and infants. Tests identified as part of the standard battery may be
considered medically necessary as part of the initial work-up of a patient with
hearing impairment in the corresponding age group.
Tests identified as specialized would not be part of the initial work-up of patients
presenting with hearing impairment, but may be considered medically necessary when
initial diagnostic tests are inconclusive. See attachment I for procedure codes and
attachment II for diagnostic codes.
Standard
Battery
Adult
Child
Infant
Pure Tone Audiometry
Air conduction
Bone conduction
Masking (if air bone gap is
present)
Pure Tone Audiometry
(Same as adult, age
dependent)
Auditory Evoked
Potentials (AEP) or
Auditory Brainstem
Response (ABR)
Speech Audiometry
Speech Recognition
Thresholds (SRT)
Word recognition ability(WR)
Basic Immittance Test
Battery
Tympanometry
Acoustic reflex Measurement
Speech Audiometry
(Same as adult, age
dependent)
Visual
Reinforcement
audiometry(VRA)
Basic Immittance Test
Battery
(Same as adult, age
dependent)
Select Picture Audiometry
Evoked
Otoacoustic
Emissions(OAE)
Conditioning Play
Audiometry
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Medical Policy Number: UM.DIAG.01
Acoustic Reflex
Measurement
Specialized
tests
Auditory Evoked Potentials
(AEP) or Auditory Brainstem
Response (ABR) in:
• Difficult to test patients
• For neurologic assessment
• To diagnose retrocochlear
pathology (e.g. acoustic
neuromas or other lesions)
Auditory Evoked Potentials
(AEP) or Auditory Brainstem
Response (ABR) (Same as adult,
age dependent)
Echocochleography(ECochG)
• To diagnose endolymphatic
hydrops
Tone Decay Test
• For diagnosis of cochlear vs.
retrocochlear (tone decay has
been largely replaced by ABR
but is still in use)
Echocochleography(ECochG)
(Same as adult, age
dependent)
Tone Decay Test
(Same as adult, age
dependent)
Stenger Test, pure tone or
speech
• For diagnosis of
pseudohypacusis
Stenger Test
(Same as adult, age
dependent)
Sensorineural Acuity Level
• For diagnosis of
pseudohypacusis
Evoked Otoacoustic
Emissions(OAE)
When a service is considered not medically necessary:
•
•
•
•
Lombard test (replaced by the Stenger test and auditory evoked potential);
Alternate binaural loudness balance test;
Short increment sensitivity test (replaced by pure tone audiometry, auditory
evoked potential);
Bekesy audiometry.
When a service is considered investigational*:
•
•
Staggered spondaic word test;
Synthetic sentence identification test.
*This policy no longer addresses tests of central auditory processing, since these tests
do not evaluate hearing impairment. See Rationale section for further general
discussion of tests of central auditory processing.
Page 3 of 48
Medical Policy Number: UM.DIAG.01
When a service is considered non-covered because it is a contract exclusion:
Unless otherwise specified in a subscriber’s certificate, certificate rider, or outline of
coverage, hearing aids and examinations for the prescription or fitting of hearing aids
is not a covered benefit.
Background & Rationale
A variety of tests have been designed to evaluate central auditory processing, which is
a higher order cortical function that processes auditory information. Therefore,
central auditory processing tests do not strictly evaluate hearing impairment, and thus
are not formally considered in this policy.
The various audiometric tests can be subdivided into standard batteries that are
typically used as part of the initial work-up of patients presenting with hearing
impairment, as well as specialized tests that are typically used in specific clinical
situations. The standard batteries vary according to whether the patient is an adult,
child, or infant. The tests are briefly defined as follows:
Standard Battery of Tests for Adults and Children
1. Pure-tone audiometry, air and bone conduction
This test is a standard audiometric study that uses tones of various frequencies and
intensities as auditory stimuli to measure hearing. As air conduction is the usual
method of sound transmission, air audiometry uses the external and middle ear in the
transmission of sound to the cochlea and beyond. Bone-conduction audiometry
involves the vibration of the skull by direct contact with an oscillating device that is
thought to set the cochlear fluids into motion, bypassing the external and middle ear.
When bone-conduction thresholds are better than air-conduction thresholds, the
hearing loss is conductive. When bone-conduction thresholds are the same as airconduction thresholds, the hearing loss is sensorineural. When bone-conduction
thresholds are reduced but are still better than air conductions, the loss is mixed or
combined.
2. Speech audiometry
This test is a standard audiometric study that measures overall performance in
hearing, understanding, and responding to speech for a general assessment of hearing
and an estimate of degree of practical handicap. It may include a speech recognition
test, in which the patient repeats words back, and a speech reception threshold,
which determines when the patient can first hear speech. It may also be used to
reaffirm the findings of the pure-tone audiometry and to diagnose pseudohypacusis (a
non-existent or false hearing loss).
3. Word recognition tests
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Medical Policy Number: UM.DIAG.01
This category includes filtered speech tests and synthetic sentence identification.
These tests specifically assess the patient’s ability to discriminate spoken words.
4. Acoustic reflex test and acoustic reflex decay
These tests measure the changes in the ear’s ability to conduct sound to the cochlea.
Reflexes, called acoustic reflexes, exist and involve middle ear function. Absence of
the acoustic reflex may be indicative, among other things, of lesions of the middle
ear, acoustic tumor, otosclerosis, facial nerve involvement of the probe ear side, and
surgical removal or congenital absence of the stapes. These tests may be used in
assessing the hearing of neonates and other children too young to cooperate in the
audiometric testing of functional hearing loss.
5. Tympanometry (impedance testing)
This is a standard series of tests to measure the ability of the middle ear to conduct
sound. It is particularly useful in the identification of fluid in the middle ear and in the
anatomic localization of facial nerve paralysis.
Additional Standard Battery of Tests for Children Only
1. Select picture audiometry
This test is used to evaluate hearing-impaired children. It involves the use of
pictures on cards and the child’s ability to correctly identify objects based on
audiologic direction.
2. Conditioning play audiometry
This is usually performed to test hearing impairment in children 2 to 4 years of age.
The child is taught to put an object in a specific place, e.g., a marble in a box or a
cow in the barnyard when a specific sound is heard.
Standard Battery of Tests for Infants Only
1. Auditory evoked potential (also called auditory brainstem response [ABR])
This is an electrophysiological measure of auditory function that uses responses
produced by the auditory nerve and the brainstem and helps differentiate sensory
from neural hearing loss. The response is the waveform averaged over many auditory
clicks. It may be helpful in the diagnosis of cerebellopontine angle tumors and acoustic
neuromas, is used as a monitor in posterior fossa surgery, and may help to establish a
hearing threshold for infants and difficult-to-test patients.
2. Visual reinforcement audiometry (VRA)
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Medical Policy Number: UM.DIAG.01
The VRA is part of a battery of tests used in the determination of infant hearing loss.
The premise of the test is that the rate of patient response is increased by the use of
reinforcement.
3. Evoked otoacoustic emissions (OAE)
Otoacoustic emissions are sounds measured in the external ear canal that are a
reflection of the working of the cochlea. Probe and click stimuli are used in the
performance of this test. OAE is used in the screening as well as the diagnosis of
hearing impairment in neonates and young children.
4. Acoustic reflex test
See Standard Battery of Tests for Adults and Children, No. 4
Specialized Tests for Adults and Children
1. Auditory Evoked Potential
See Standard Battery of Tests for Infants Only, No. 1
2. Electrocochleography (ECochG)
This is a measure of the electrical potentials generated in the inner ear as a result of
sound stimulation. This test may be used in the evaluation of endolymphatic hydrops
or Meniere’s disease.
3. Tone decay test
This test involves the presentation of a continuous tone to determine whether the
threshold for the tone has changed (becomes poorer) over time. The test helps
differentiate sensory from neural hearing loss, and is used in the diagnosis of cochlear
versus retrocochlear lesions and eighth nerve tumors. While this test is still in use, the
auditory evoked potential test is largely used in place of the tone decay test.
4. Stenger test, pure tone or speech
This test uses a tone presented simultaneously to both ears and is based on the
principle that the tone is perceived only in the ear that receives the greater intensity.
It is useful in the diagnosis of pseudohypacusis (hypacusis is a hearing impairment of a
conductive or a neurosensory nature, and pseudohypacusis is a non- existent [false]
hearing loss.)
5. Sensorineural acuity level (SAL) test
This test measures the extent of sensorineural hearing loss and is also used in the
detection of pseudohypacusis among children. It is not a commonly performed test.
There are several different tests in use, including one in which a bone-conduction
vibrator is placed at the center of the forehead and the threshold shift for a normal
ear versus an ear with sensorineural hearing loss is analyzed.
6. Evoked otoacoustic emissions
While this test is considered part of the standard battery of tests in infants, it is
considered a specialized test in adults and children. For a description, see Standard
Battery of Tests for Infants Only, No. 3.
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Medical Policy Number: UM.DIAG.01
The tests of hearing impairment listed in the policy here are considered standard tests
of hearing impairment and thus the specific diagnostic parameters of each of these
tests will not be considered further. In 2000, the American Academy of Pediatrics, as a
participant in the Joint Committee on Infant Hearing, published a position statement
regarding early hearing detection. (1) This statement recommended that all infants
have access to hearing screening using a physiologic measure, with the goal that all
infants who do not pass the birth admission screen and any subsequent rescreening
begin appropriate audiologic and medical evaluations to confirm the presence of
hearing loss before 3 months of age. The position statement noted that otoacoustic
emission (OAEs) or auditory brainstem response (ABR) are physiologic techniques that
have been successfully used for newborn screening. For example, hospitals may screen
with otoacoustic emissions technology or auditory brainstem response technology and
retest infants who "refer" with the same or other technology.
Central Auditory Processing
When this policy was first issued in 1997, tests of central auditory processing (CAP)
were considered investigational. These tests are no longer formally considered in the
policy statement, since tests of central auditory processing are not tests of hearing
impairment, per se, but tests of how auditory information is processed by the brain.
For example, central auditory processes are responsible for sound localization and
lateralization, auditory discrimination, auditory pattern recognition, and temporal
aspects of audition. Tests of CAP are commonly recommended for children with
dyslexia, attention deficit disorder, or other learning or behavioral disabilities. (2) The
results of the test may be used to tailor specific teaching or behavioral strategies, and
thus depending on the contract or benefit design may be considered part of the
mental health benefits, or contractually excluded as an evaluation of a learning
disability.
A literature search based on the PubMed US national library of Medicine, National
Institutes of Health database for the period of 2004 through June 2015 did not identify
additional articles that would prompt reconsideration of the policy statement, which
remains unchanged.
Reference Resources
1. BCBSA Policy 9.01.02 – Archived June 2010
2. American Academy of Pediatrics. Year 2007 position statement: principles and
guidelines for early hearing detection and intervention programs. Pediatrics 2007;
120(4):898-921.
3. Bamiou DE, Musiek FE, Luxon LM. Aetiology and clinical presentations of auditory
processing disorders – a review. Arch Dis Child 2001; 85(5):361-5.
4. Amos NE, Humes LE. SCAN test-retest reliability for first and third grade children. J
Speech Lang Hear Res 1998; 41(4):834-45.
5. Domitz DM, Schow RL. A new CAPD battery – multiple processing assessment:
factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2):101-11.
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Medical Policy Number: UM.DIAG.01
6. Task Force on Central Auditory Processing Consensus Development. American
Speech-Language-Hearing Association. Central auditory processing: Current status
of research and implications for clinical practice. Am J Audiol 1996; 5:41-54.
7. Jerger J, Musiek F. Report of the Consensus Conference on the Diagnosis of
Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000;
11(9):467-74.
Document Precedence
Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to
provide clinical guidance and are based on research of current medical literature and
review of common medical practices in the treatment and diagnosis of disease. The
applicable group/individual contract and member certificate language determines
benefits that are in effect at the time of service. Since medical practices and
knowledge are constantly evolving, BCBSVT reserves the right to review and revise its
medical policies periodically. To the extent that there may be any conflict between
medical policy and contract language, the member’s contract language takes
precedence.
Audit Information
BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure
compliance with the guidelines stated in the medical policy. If an audit identifies
instances of non-compliance with this medical policy, BCBSVT reserves the right to
recoup all non-compliant payments.
Eligible Providers
Eligible providers practicing within the scope of their license(s), including:
Allopathic Physicians
Osteopathic Physicians
Naturopathic Physicians
Audiologists
Speech-Language Pathologists
Advanced Practice Registered Nurses
Administrative and Contractual Guidance
Benefit Determination Guidance
Benefits are subject to all terms, limitations and conditions of the subscriber contract.
An approved referral authorization for members of the New England Health Plan
(NEHP) is required. NEHP/ABNE members may have different benefits for services
listed in this policy. To confirm benefits, please contact the customer service
department at the member’s health plan.
Page 8 of 48
Medical Policy Number: UM.DIAG.01
Federal Employee Program (FEP) members may have different benefits that apply. For
further information please contact FEP customer service or refer to the FEP Service
Benefit Plan Brochure.
Coverage varies according to the member’s group or individual contract. Not all groups
are required to follow the Vermont legislative mandates. Member Contract language
takes precedence over medical policy when there is a conflict.
If the member receives benefits through a self-funded (ASO) group, benefits may vary
or not apply. To verify benefit information, please refer to the member’s plan
documents or contact the customer service department.
Individual employer groups may have benefits for hearing aids and/or examinations
that are subject to the terms, limitations and conditions of the subscriber contract or
employer benefit plan documents. Cochlear implants are not considered to be
“hearing aids” and are not addressed under this policy.
Policy Implementation/Update information
12/2005
06/2007
07/2007
06/2008
07/2008
11/2009
01/2010
08/2011
09/2011
02/2014
06/2015
01/2016
Reviewed replacement battery codes added to attachment.
Clarified benefit, corrected and added new CPT codes
Added CPT codes
Reviewed by CAC
Annual review. No clinical changes made. Minor changes to
attachment page.
Reviewed by CAC
Name changed to match BCBSA Medical Policy and
incorporated language and criteria; audiologists and speechlanguage pathologists added as providers; and when services
are not covered was clarified. Cerumen removal was removed
from policy as not applicable
Reviewed by CAC
Policy converted to new format
Policy adopted
Coding is appropriate per Medical/Clinical Coder SAR
ICD-10 remediation only. SAR
Vestibular CPTs added. S0618 added to non-covered section.
Providers encouraged to use more appropriate CPT code.
Reviewed and approved by MPC on 06/08/15.
CPT code updates to reflect AMA CPT changes.
Approved by BCBSVT Medical Directors
Joshua Plavin, MD
Senior Medical Director
Page 9 of 48
Medical Policy Number: UM.DIAG.01
Date Approved
Chair, Medical Policy Committee
Robert Wheeler MD
Chief Medical Officer
Attachment I
CPT coding table & instructions
Code
Type
Number
Description
Policy Instructions
The following codes will be considered as medically necessary when applicable
criteria have been met.
CPT
CPT
CPT
CPT
92506
Evaluation of speech, language,
voice, communication, auditory
processing, and/or aural
rehabilitation status
92507
Treatment of speech, language
voice, communication, and/or
auditory processing disorder
(includes aural rehabilitation);
individual
92537
Caloric vestibular test with
recording, bilateral; bithermal (ie,
one warm and one cool irrigation in
each ear for a total of four
irrigations)
92538
Caloric vestibular test with
recording, bilateral; monothermal
(ie, one irrigation in each ear for a
total of two irrigations)
Page 10 of 48
Medical Policy Number: UM.DIAG.01
CPT
92540
Basic vestibular evaluation, includes
spontaneous nystagmus test with
eccentric gaze fixation nystagmus,
with recording, positional nystagmus
test, minimum of 4 positions, with
recording, optokinetic nystagmus
test, bidirectional foveal and
peripheral stimulation, with
recording, and oscillating tracking
test, with recording
CPT
92541
Spontaneous nystagmus test,
including gaze and fixation
nystagmus, with recording
CPT
92542
Positional nystagmus test, minimum
of 4 positions, with recording
CPT
92544
Optokinetic nystagmus test,
bidirectional, foveal or peripheral
stimulation, with recording
CPT
92545
Oscillating tracking test, with
recording
CPT
92546
Sinusoidal vertical axis rotational
testing
CPT
92547
Use of vertical electrodes (List
separately in addition to code for
primary procedure)
CPT
92550
Tympanometry and reflex threshold
measurements
CPT
92551
Screening test, pure tone, air only
May be subject to *PPACA
for certain preventative
diagnoses.
CPT
92552
Pure tone audiometry (threshold);air
only
May be subject to *PPACA
for certain preventative
diagnoses.
CPT
92553
Pure air and bone audiometry
CPT
92555
Speech audiometry threshold
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Medical Policy Number: UM.DIAG.01
92556
Speech audiometry threshold; with
speech recognition
CPT
92557
Comprehensive audiometry
threshold evaluation and speech
recognition ( 92553 and 92556
combined)
CPT
92563
Tone decay test
CPT
92565
Stenger test, pure tone
CPT
92567
Tympanometry (impedance testing)
CPT
92568
Acoustic reflex testing
CPT
92569
Acoustic reflex decay test
CPT
92570
Acoustic Inmittance testing
CPT
92571
Filtered speech test
CPT
92575
Sensorineural acuity level test
CPT
92577
Stenger test, speech
CPT
92579
Visual reinforcement audiometry
(VRA)
CPT
92582
Conditioning play audiometry
CPT
92583
Select picture audiometry
CPT
92584
Electrocochleography
CPT
9258592586
Auditory evoked potentials for
evoked response audiometry and/or
testing of the central nervous
system; comprehensive
May be subject to *PPACA
for certain preventative
diagnoses. Ages 1 or
younger.
92587
Evoked otoacoustic emissions;
limited (single stimulus level, either
transient or distortion products)
May be subject to *PPACA
for certain preventative
diagnoses. Ages 1 or
younger.
92588
Evoked otoacoustic emissions:
comprehensive or diagnostic
evaluation (comparisons of transient
and/or distortion product
otoacoustic emissions at multiple
levels and frequencies)
CPT
CPT
CPT
Page 12 of 48
Medical Policy Number: UM.DIAG.01
CPT
92620
Evaluation of central auditory
function, with report; initial 60
minutes
CPT
92621
Each additional 15 minutes
CPT
92625
Assessment of tinnitus (includes
pitch, loudness, matching and
masking.)
The following codes will be denied as Not Medically Necessary, Non-Covered,
Contract Exclusions or Investigational
Investigational except
for; May be subject to
*PPACA for certain
preventative diagnoses.
CPT
92548
Computerized Dynamic
Posturography
CPT
92559
Audiometric testing of groups
Not Medically Necessary
CPT
92560
Bekesy audiometry; screening
Not Medically Necessary
CPT
92561
Bekesy diagnostic
Not Medically Necessary
CPT
92562
Loudness balance test, alternate
binaural or monaural
Not Medically Necessary
CPT
92564
Short Increment Sensitivity index
SISI
Not Medically Necessary
CPT
92572
Staggered spondaic word test
Investigational
CPT
92576
Synthetic sentence identification
test
Investigational
CPT
92589
Hearing aid examination and
selection, monaural
Contract Exclusion
CPT
92590
Hearing aid examination and
selection; monaural
Contract Exclusion
CPT
92591
Hearing aid examination and
selection; binaural
Contract Exclusion
CPT
92592
Hearing aid check; monaural
Contract Exclusion
CPT
92593
Hearing aid check; binaural
Contract Exclusion
CPT
92594
Electroacoustic evaluation for
hearing aid; monaural
Contract Exclusion
Page 13 of 48
Medical Policy Number: UM.DIAG.01
CPT
92595
Electroacoustic evaluation for
hearing aid; binaural
Contract Exclusion
CPT
92596
Ear protector attenuation
measurements
Not Medically Necessary
CPT
92700
Unlisted otorhinolaryngological
service or procedure
Not Medically Necessary
S0618
Audiometry for hearing aid
evaluation to determine the level
and degree of hearing loss
Non-covered. Please use
CPT that more accurately
describes the service.
HCPCS
Type of Service
Medicine
Place of Service
Outpatient, office
011116RLG
Attachment II
ICD-10 coding table
The following diagnoses are considered medically necessary when applicable
criteria in this policy is met.
ICD-10
Description
B45.1
Cerebral cryptococcosis
C70.1
Malignant neoplasm of
spinal meninges
C71.6
Malignant neoplasm of
cerebellum
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Medical Policy Number: UM.DIAG.01
ICD-10
Description
H75.82
Other specified disorders
of left middle ear and
mastoid in diseases
classified elsewhere
H75.83
Other specified disorders
of middle ear and mastoid
in diseases classified
elsewhere, bilateral
H80.00
Otosclerosis involving oval
window, nonobliterative,
unspecified ear
C79.31
Secondary malignant
neoplasm of brain
H80.01
Otosclerosis involving oval
window, nonobliterative,
right ear
C79.32
Secondary malignant
neoplasm of cerebral
meninges
H80.02
Otosclerosis involving oval
window, nonobliterative,
left ear
C79.40
Secondary malignant
neoplasm of unspecified
part of nervous system
H80.03
Otosclerosis involving oval
window, nonobliterative,
bilateral
C79.49
Secondary malignant
neoplasm of other parts of
nervous system
H80.10
Otosclerosis involving oval
window, obliterative,
unspecified ear
D32.0
Benign neoplasm of
cerebral meninges
H80.11
Otosclerosis involving oval
window, obliterative, right
ear
D32.1
Benign neoplasm of spinal
meninges
H80.12
Otosclerosis involving oval
window, obliterative, left
ear
D32.9
Benign neoplasm of
meninges, unspecified
H80.13
Otosclerosis involving oval
window, obliterative,
bilateral
D33.0
Benign neoplasm of brain,
supratentorial
H80.20
Cochlear otosclerosis,
unspecified ear
D33.1
Benign neoplasm of brain,
infratentorial
H80.21
Cochlear otosclerosis, right
ear
D33.2
Benign neoplasm of brain,
unspecified
H80.22
Cochlear otosclerosis, left
ear
D33.3
Benign neoplasm of cranial
nerves
H80.23
Cochlear otosclerosis,
bilateral
D42.0
Neoplasm of uncertain
behavior of cerebral
meninges
H80.80
Other otosclerosis,
unspecified ear
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Medical Policy Number: UM.DIAG.01
D42.1
Neoplasm of uncertain
behavior of spinal
meninges
H80.81
Other otosclerosis, right
ear
D42.9
Neoplasm of uncertain
behavior of meninges,
unspecified
H80.82
Other otosclerosis, left ear
D43.0
Neoplasm of uncertain
behavior of brain,
supratentorial
H80.83
Other otosclerosis,
bilateral
D43.1
Neoplasm of uncertain
behavior of brain,
infratentorial
H80.90
Unspecified otosclerosis,
unspecified ear
D43.2
Neoplasm of uncertain
behavior of brain,
unspecified
H80.91
Unspecified otosclerosis,
right ear
D43.3
Neoplasm of uncertain
behavior of cranial nerves
H80.92
Unspecified otosclerosis,
left ear
D43.4
Neoplasm of uncertain
behavior of spinal cord
H80.93
Unspecified otosclerosis,
bilateral
D43.8
Neoplasm of uncertain
behavior of other specified
parts of central nervous
system
H81.01
Ménière's disease, right ear
D43.9
Neoplasm of uncertain
behavior of central nervous
system, unspecified
H81.02
Ménière's disease, left ear
D49.6
Neoplasm of unspecified
behavior of brain
H81.03
Ménière's disease, bilateral
D49.7
Neoplasm of unspecified
behavior of endocrine
glands and other parts of
nervous system
H81.09
Ménière's disease,
unspecified ear
G00.0
Hemophilus meningitis
H81.10
Benign paroxysmal vertigo,
unspecified ear
Page 16 of 48
Medical Policy Number: UM.DIAG.01
G00.1
Pneumococcal meningitis
H81.11
Benign paroxysmal vertigo,
right ear
G00.2
Streptococcal meningitis
H81.12
Benign paroxysmal vertigo,
left ear
G00.3
Staphylococcal meningitis
H81.13
Benign paroxysmal vertigo,
bilateral
G00.8
Other bacterial meningitis
H81.20
Vestibular neuronitis,
unspecified ear
G00.9
Bacterial meningitis,
unspecified
H81.21
Vestibular neuronitis, right
ear
H81.22
Vestibular neuronitis, left
ear
H81.23
Vestibular neuronitis,
bilateral
G01
G02
Meningitis in bacterial
diseases classified
elsewhere
Meningitis in other
infectious and parasitic
diseases classified
elsewhere
G03.0
Nonpyogenic meningitis
H81.311
Aural vertigo, right ear
G03.1
Chronic meningitis
H81.312
Aural vertigo, left ear
G03.8
Meningitis due to other
specified causes
H81.313
Aural vertigo, bilateral
G03.9
Meningitis, unspecified
H81.319
Aural vertigo, unspecified
ear
G04.2
Bacterial
meningoencephalitis and
meningomyelitis, not
elsewhere classified
H81.391
Other peripheral vertigo,
right ear
G09
Sequelae of inflammatory
diseases of central nervous
system
H81.392
Other peripheral vertigo,
left ear
G51.0
Bell's palsy
H81.393
Other peripheral vertigo,
bilateral
G96.0
Cerebrospinal fluid leak
H81.399
Other peripheral vertigo,
unspecified ear
Page 17 of 48
Medical Policy Number: UM.DIAG.01
H65.00
Acute serous otitis media,
unspecified ear
H81.41
Vertigo of central origin,
right ear
H65.01
Acute serous otitis media,
right ear
H81.42
Vertigo of central origin,
left ear
H65.02
Acute serous otitis media,
left ear
H81.43
Vertigo of central origin,
bilateral
H65.03
Acute serous otitis media,
bilateral
H81.49
Vertigo of central origin,
unspecified ear
H65.04
Acute serous otitis media,
recurrent, right ear
H81.8x1
Other disorders of
vestibular function, right
ear
H65.05
Acute serous otitis media,
recurrent, left ear
H81.8x2
H65.06
Acute serous otitis media,
recurrent, bilateral
H81.8x3
H65.07
Acute serous otitis media,
recurrent, unspecified ear
H81.8x9
Other disorders of
vestibular function,
unspecified ear
H65.111
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), right ear
H81.90
Unspecified disorder of
vestibular function,
unspecified ear
H65.112
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), left ear
H81.91
Unspecified disorder of
vestibular function, right
ear
H65.113
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), bilateral
H81.92
Unspecified disorder of
vestibular function, left
ear
Page 18 of 48
Medical Policy Number: UM.DIAG.01
Other disorders of
vestibular function, left
ear
Other disorders of
vestibular function,
bilateral
H65.114
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), recurrent, right
ear
H81.93
Unspecified disorder of
vestibular function,
bilateral
H65.115
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), recurrent, left
ear
H82.1
Vertiginous syndromes in
diseases classified
elsewhere, right ear
H65.116
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), recurrent,
bilateral
H82.2
Vertiginous syndromes in
diseases classified
elsewhere, left ear
H65.117
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), recurrent,
unspecified ear
H82.3
Vertiginous syndromes in
diseases classified
elsewhere, bilateral
H65.119
Acute and subacute
allergic otitis media
(mucoid) (sanguinous)
(serous), unspecified ear
H82.9
Vertiginous syndromes in
diseases classified
elsewhere, unspecified ear
H83.01
Labyrinthitis, right ear
H83.02
Labyrinthitis, left ear
H83.03
Labyrinthitis, bilateral
H65.191
H65.192
H65.193
Other acute
nonsuppurative otitis
media, right ear
Other acute
nonsuppurative otitis
media, left ear
Other acute
nonsuppurative otitis
media, bilateral
H65.194
Other acute
nonsuppurative otitis
media, recurrent, right ear
H83.09
Labyrinthitis, unspecified
ear
H65.195
Other acute
nonsuppurative otitis
media, recurrent, left ear
H83.11
Labyrinthine fistula, right
ear
Page 19 of 48
Medical Policy Number: UM.DIAG.01
H65.196
Other acute
nonsuppurative otitis
media, recurrent, bilateral
H83.12
Labyrinthine fistula, left
ear
H65.197
Other acute
nonsuppurative otitis
media recurrent,
unspecified ear
H83.13
Labyrinthine fistula,
bilateral
H65.199
Other acute
nonsuppurative otitis
media, unspecified ear
H83.19
Labyrinthine fistula,
unspecified ear
H65.20
Chronic serous otitis
media, unspecified ear
H83.2x1
Labyrinthine dysfunction,
right ear
H65.21
Chronic serous otitis
media, right ear
H83.2x2
Labyrinthine dysfunction,
left ear
H65.22
Chronic serous otitis
media, left ear
H83.2x3
Labyrinthine dysfunction,
bilateral
H65.23
Chronic serous otitis
media, bilateral
H83.2x9
Labyrinthine dysfunction,
unspecified ear
H65.30
Chronic mucoid otitis
media, unspecified ear
H83.3x1
Noise effects on right inner
ear
H65.31
Chronic mucoid otitis
media, right ear
H83.3x2
Noise effects on left inner
ear
H65.32
Chronic mucoid otitis
media, left ear
H83.3x3
Noise effects on inner ear,
bilateral
H65.33
Chronic mucoid otitis
media, bilateral
H83.3x9
Noise effects on inner ear,
unspecified ear
H65.411
Chronic allergic otitis
media, right ear
H83.8x1
Other specified diseases of
right inner ear
H65.412
Chronic allergic otitis
media, left ear
H83.8x2
Other specified diseases of
left inner ear
H65.413
Chronic allergic otitis
media, bilateral
H83.8x3
Other specified diseases of
inner ear, bilateral
H65.419
Chronic allergic otitis
media, unspecified ear
H83.8x9
Other specified diseases of
inner ear, unspecified ear
Page 20 of 48
Medical Policy Number: UM.DIAG.01
H65.491
Other chronic
nonsuppurative otitis
media, right ear
H83.90
Unspecified disease of
inner ear, unspecified ear
H65.492
Other chronic
nonsuppurative otitis
media, left ear
H83.91
Unspecified disease of
right inner ear
H65.493
Other chronic
nonsuppurative otitis
media, bilateral
H83.92
Unspecified disease of left
inner ear
H65.499
Other chronic
nonsuppurative otitis
media, unspecified ear
H83.93
Unspecified disease of
inner ear, bilateral
H65.90
Unspecified nonsuppurative
otitis media, unspecified
ear
H90.0
Conductive hearing loss,
bilateral
H65.91
Unspecified nonsuppurative
otitis media, right ear
H90.11
Conductive hearing loss,
unilateral, right ear, with
unrestricted hearing on the
contralateral side
H65.92
Unspecified nonsuppurative
otitis media, left ear
H90.12
Conductive hearing loss,
unilateral, left ear, with
unrestricted hearing on the
contralateral side
H65.93
Unspecified nonsuppurative
otitis media, bilateral
H90.2
Conductive hearing loss,
unspecified
H66.001
Acute suppurative otitis
media without spontaneous
rupture of ear drum, right
ear
H90.3
Sensorineural hearing loss,
bilateral
H66.002
Acute suppurative otitis
media without spontaneous
rupture of ear drum, left
ear
H90.41
Sensorineural hearing loss,
unilateral, right ear, with
unrestricted hearing on the
contralateral side
Page 21 of 48
Medical Policy Number: UM.DIAG.01
H66.003
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
bilateral
H90.42
Sensorineural hearing loss,
unilateral, left ear, with
unrestricted hearing on the
contralateral side
H66.004
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
recurrent, right ear
H90.5
Unspecified sensorineural
hearing loss
H66.005
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
recurrent, left ear
H90.6
Mixed conductive and
sensorineural hearing loss,
bilateral
H66.006
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
recurrent, bilateral
H90.71
Mixed conductive and
sensorineural hearing loss,
unilateral, right ear, with
unrestricted hearing on the
contralateral side
H66.007
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
recurrent, unspecified ear
H90.72
Mixed conductive and
sensorineural hearing loss,
unilateral, left ear, with
unrestricted hearing on the
contralateral side
H66.009
Acute suppurative otitis
media without spontaneous
rupture of ear drum,
unspecified ear
H90.8
Mixed conductive and
sensorineural hearing loss,
unspecified
H66.011
Acute suppurative otitis
media with spontaneous
rupture of ear drum, right
ear
H91.01
Ototoxic hearing loss, right
ear
H66.012
Acute suppurative otitis
media with spontaneous
rupture of ear drum, left
ear
H91.02
Ototoxic hearing loss, left
ear
Page 22 of 48
Medical Policy Number: UM.DIAG.01
H66.013
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
bilateral
H91.03
Ototoxic hearing loss,
bilateral
H66.014
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
recurrent, right ear
H91.09
Ototoxic hearing loss,
unspecified ear
H66.015
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
recurrent, left ear
H91.10
Presbycusis, unspecified
ear
H66.016
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
recurrent, bilateral
H91.11
Presbycusis, right ear
H66.017
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
recurrent, unspecified ear
H91.12
Presbycusis, left ear
H66.019
Acute suppurative otitis
media with spontaneous
rupture of ear drum,
unspecified ear
H91.13
Presbycusis, bilateral
H66.10
Chronic tubotympanic
suppurative otitis media,
unspecified
H91.20
Sudden idiopathic hearing
loss, unspecified ear
H66.11
Chronic tubotympanic
suppurative otitis media,
right ear
H91.21
Sudden idiopathic hearing
loss, right ear
H66.12
Chronic tubotympanic
suppurative otitis media,
left ear
H91.22
Sudden idiopathic hearing
loss, left ear
Page 23 of 48
Medical Policy Number: UM.DIAG.01
H66.13
Chronic tubotympanic
suppurative otitis media,
bilateral
H91.23
Sudden idiopathic hearing
loss, bilateral
H66.20
Chronic atticoantral
suppurative otitis media,
unspecified ear
H91.3
Deaf nonspeaking, not
elsewhere classified
H66.21
Chronic atticoantral
suppurative otitis media,
right ear
H91.8x1
Other specified hearing
loss, right ear
H66.22
Chronic atticoantral
suppurative otitis media,
left ear
H91.8x2
Other specified hearing
loss, left ear
H66.23
Chronic atticoantral
suppurative otitis media,
bilateral
H91.8x3
Other specified hearing
loss, bilateral
H66.3x1
Other chronic suppurative
otitis media, right ear
H91.8x9
Other specified hearing
loss, unspecified ear
H66.3x2
Other chronic suppurative
otitis media, left ear
H91.90
Unspecified hearing loss,
unspecified ear
H66.3x3
Other chronic suppurative
otitis media, bilateral
H91.91
Unspecified hearing loss,
right ear
H66.3x9
Other chronic suppurative
otitis media, unspecified
ear
H91.92
Unspecified hearing loss,
left ear
H66.40
Suppurative otitis media,
unspecified, unspecified
ear
H91.93
Unspecified hearing loss,
bilateral
H66.41
Suppurative otitis media,
unspecified, right ear
H92.01
Otalgia, right ear
H66.42
Suppurative otitis media,
unspecified, left ear
H92.02
Otalgia, left ear
H66.43
Suppurative otitis media,
unspecified, bilateral
H92.03
Otalgia, bilateral
Page 24 of 48
Medical Policy Number: UM.DIAG.01
H66.90
Otitis media, unspecified,
unspecified ear
H92.09
Otalgia, unspecified ear
H66.91
Otitis media, unspecified,
right ear
H92.10
Otorrhea, unspecified ear
H66.92
Otitis media, unspecified,
left ear
H92.11
Otorrhea, right ear
H66.93
Otitis media, unspecified,
bilateral
H92.12
Otorrhea, left ear
H67.1
Otitis media in diseases
classified elsewhere, right
ear
H92.13
Otorrhea, bilateral
H67.2
Otitis media in diseases
classified elsewhere, left
ear
H92.20
Otorrhagia, unspecified ear
H67.3
Otitis media in diseases
classified elsewhere,
bilateral
H92.21
Otorrhagia, right ear
H67.9
Otitis media in diseases
classified elsewhere,
unspecified ear
H92.22
Otorrhagia, left ear
H68.001
Unspecified Eustachian
salpingitis, right ear
H92.23
Otorrhagia, bilateral
H68.002
Unspecified Eustachian
salpingitis, left ear
H93.011
Transient ischemic
deafness, right ear
H68.003
Unspecified Eustachian
salpingitis, bilateral
H93.012
Transient ischemic
deafness, left ear
H68.009
Unspecified Eustachian
salpingitis, unspecified ear
H93.013
Transient ischemic
deafness, bilateral
H68.011
Acute Eustachian
salpingitis, right ear
H93.019
Transient ischemic
deafness, unspecified ear
H68.012
Acute Eustachian
salpingitis, left ear
H93.091
Unspecified degenerative
and vascular disorders of
right ear
Page 25 of 48
Medical Policy Number: UM.DIAG.01
H68.013
Acute Eustachian
salpingitis, bilateral
H93.092
Unspecified degenerative
and vascular disorders of
left ear
H68.019
Acute Eustachian
salpingitis, unspecified ear
H93.093
Unspecified degenerative
and vascular disorders of
ear, bilateral
H68.021
Chronic Eustachian
salpingitis, right ear
H93.099
Unspecified degenerative
and vascular disorders of
unspecified ear
H68.022
Chronic Eustachian
salpingitis, left ear
H93.11
Tinnitus, right ear
H68.023
Chronic Eustachian
salpingitis, bilateral
H93.12
Tinnitus, left ear
H68.029
Chronic Eustachian
salpingitis, unspecified ear
H93.13
Tinnitus, bilateral
H68.101
Unspecified obstruction of
Eustachian tube, right ear
H93.19
Tinnitus, unspecified ear
H68.102
Unspecified obstruction of
Eustachian tube, left ear
H93.211
Auditory recruitment, right
ear
H68.103
Unspecified obstruction of
Eustachian tube, bilateral
H93.212
Auditory recruitment, left
ear
H68.109
Unspecified obstruction of
Eustachian tube,
unspecified ear
H93.213
Auditory recruitment,
bilateral
H68.111
Osseous obstruction of
Eustachian tube, right ear
H93.219
Auditory recruitment,
unspecified ear
H68.112
Osseous obstruction of
Eustachian tube, left ear
H93.221
Diplacusis, right ear
H68.113
Osseous obstruction of
Eustachian tube, bilateral
H93.222
Diplacusis, left ear
H68.119
Osseous obstruction of
Eustachian tube,
unspecified ear
H93.223
Diplacusis, bilateral
Page 26 of 48
Medical Policy Number: UM.DIAG.01
H68.121
Intrinsic cartilagenous
obstruction of Eustachian
tube, right ear
H93.229
Diplacusis, unspecified ear
H68.122
Intrinsic cartilagenous
obstruction of Eustachian
tube, left ear
H93.231
Hyperacusis, right ear
H68.123
Intrinsic cartilagenous
obstruction of Eustachian
tube, bilateral
H93.232
Hyperacusis, left ear
H68.129
Intrinsic cartilagenous
obstruction of Eustachian
tube, unspecified ear
H93.233
Hyperacusis, bilateral
H68.131
Extrinsic cartilagenous
obstruction of Eustachian
tube, right ear
H93.239
Hyperacusis, unspecified
ear
H68.132
Extrinsic cartilagenous
obstruction of Eustachian
tube, left ear
H93.241
Temporary auditory
threshold shift, right ear
H68.133
Extrinsic cartilagenous
obstruction of Eustachian
tube, bilateral
H93.242
Temporary auditory
threshold shift, left ear
H68.139
Extrinsic cartilagenous
obstruction of Eustachian
tube, unspecified ear
H93.243
Temporary auditory
threshold shift, bilateral
H69.00
Patulous Eustachian tube,
unspecified ear
H93.249
Temporary auditory
threshold shift, unspecified
ear
H69.01
Patulous Eustachian tube,
right ear
H93.291
Other abnormal auditory
perceptions, right ear
H69.02
Patulous Eustachian tube,
left ear
H93.292
Other abnormal auditory
perceptions, left ear
H69.03
Patulous Eustachian tube,
bilateral
H93.293
Other abnormal auditory
perceptions, bilateral
Page 27 of 48
Medical Policy Number: UM.DIAG.01
H69.80
Other specified disorders
of Eustachian tube,
unspecified ear
H93.299
Other abnormal auditory
perceptions, unspecified
ear
H69.81
Other specified disorders
of Eustachian tube, right
ear
H93.3x1
Disorders of right acoustic
nerve
H69.82
Other specified disorders
of Eustachian tube, left ear
H93.3x2
Disorders of left acoustic
nerve
H93.3x3
Disorders of bilateral
acoustic nerves
H93.3x9
Disorders of unspecified
acoustic nerve
H69.83
H69.90
Other specified disorders
of Eustachian tube,
bilateral
Unspecified Eustachian
tube disorder, unspecified
ear
H69.91
Unspecified Eustachian
tube disorder, right ear
H93.8x1
Other specified disorders
of right ear
H69.92
Unspecified Eustachian
tube disorder, left ear
H93.8x2
Other specified disorders
of left ear
H69.93
Unspecified Eustachian
tube disorder, bilateral
H93.8x3
Other specified disorders
of ear, bilateral
H70.001
Acute mastoiditis without
complications, right ear
H93.8x9
Other specified disorders
of ear, unspecified ear
H70.002
Acute mastoiditis without
complications, left ear
H93.90
Unspecified disorder of
ear, unspecified ear
H70.003
Acute mastoiditis without
complications, bilateral
H93.91
Unspecified disorder of
right ear
H70.009
Acute mastoiditis without
complications, unspecified
ear
H93.92
Unspecified disorder of left
ear
H70.011
Subperiosteal abscess of
mastoid, right ear
H93.93
Unspecified disorder of
ear, bilateral
H70.012
Subperiosteal abscess of
mastoid, left ear
H94.00
Acoustic neuritis in
infectious and parasitic
diseases classified
elsewhere, unspecified ear
Page 28 of 48
Medical Policy Number: UM.DIAG.01
H94.01
Acoustic neuritis in
infectious and parasitic
diseases classified
elsewhere, right ear
H94.02
Acoustic neuritis in
infectious and parasitic
diseases classified
elsewhere, left ear
H70.091
Acute mastoiditis with
other complications, right
ear
H94.03
Acoustic neuritis in
infectious and parasitic
diseases classified
elsewhere, bilateral
H70.092
Acute mastoiditis with
other complications, left
ear
H94.80
Other specified disorders
of ear in diseases classified
elsewhere, unspecified ear
H70.093
Acute mastoiditis with
other complications,
bilateral
H94.81
Other specified disorders
of right ear in diseases
classified elsewhere
H70.099
Acute mastoiditis with
other complications,
unspecified ear
H94.82
Other specified disorders
of left ear in diseases
classified elsewhere
H70.10
Chronic mastoiditis,
unspecified ear
H94.83
Other specified disorders
of ear in diseases classified
elsewhere, bilateral
H70.11
Chronic mastoiditis, right
ear
H95.00
Recurrent cholesteatoma
of postmastoidectomy
cavity, unspecified ear
H70.12
Chronic mastoiditis, left
ear
H95.01
Recurrent cholesteatoma
of postmastoidectomy
cavity, right ear
H70.13
Chronic mastoiditis,
bilateral
H95.02
Recurrent cholesteatoma
of postmastoidectomy
cavity, left ear
H70.013
Subperiosteal abscess of
mastoid, bilateral
H70.019
Subperiosteal abscess of
mastoid, unspecified ear
Page 29 of 48
Medical Policy Number: UM.DIAG.01
H70.201
Unspecified petrositis,
right ear
H95.03
Recurrent cholesteatoma
of postmastoidectomy
cavity, bilateral ears
H70.202
Unspecified petrositis, left
ear
H95.111
Chronic inflammation of
postmastoidectomy cavity,
right ear
H70.203
Unspecified petrositis,
bilateral
H95.112
Chronic inflammation of
postmastoidectomy cavity,
left ear
H70.209
Unspecified petrositis,
unspecified ear
H95.113
Chronic inflammation of
postmastoidectomy cavity,
bilateral ears
H70.211
Acute petrositis, right ear
H95.119
Chronic inflammation of
postmastoidectomy cavity,
unspecified ear
H70.212
Acute petrositis, left ear
H95.121
Granulation of
postmastoidectomy cavity,
right ear
H70.213
Acute petrositis, bilateral
H95.122
Granulation of
postmastoidectomy cavity,
left ear
H70.219
Acute petrositis,
unspecified ear
H95.123
Granulation of
postmastoidectomy cavity,
bilateral ears
H70.221
Chronic petrositis, right
ear
H95.129
Granulation of
postmastoidectomy cavity,
unspecified ear
H70.222
Chronic petrositis, left ear
H95.131
Mucosal cyst of
postmastoidectomy cavity,
right ear
H70.223
Chronic petrositis, bilateral
H95.132
Mucosal cyst of
postmastoidectomy cavity,
left ear
Page 30 of 48
Medical Policy Number: UM.DIAG.01
H70.229
Chronic petrositis,
unspecified ear
H95.133
Mucosal cyst of
postmastoidectomy cavity,
bilateral ears
H70.811
Postauricular fistula, right
ear
H95.139
Mucosal cyst of
postmastoidectomy cavity,
unspecified ear
H70.812
Postauricular fistula, left
ear
H95.191
Other disorders following
mastoidectomy, right ear
H70.813
Postauricular fistula,
bilateral
H95.192
Other disorders following
mastoidectomy, left ear
H70.819
Postauricular fistula,
unspecified ear
H95.193
Other disorders following
mastoidectomy, bilateral
ears
H70.891
Other mastoiditis and
related conditions, right
ear
H95.199
Other disorders following
mastoidectomy,
unspecified ear
H95.21
Intraoperative hemorrhage
and hematoma of ear and
mastoid process
complicating a procedure
on the ear and mastoid
process
H95.22
Intraoperative hemorrhage
and hematoma of ear and
mastoid process
complicating other
procedure
H95.31
Accidental puncture and
laceration of the ear and
mastoid process during a
procedure on the ear and
mastoid process
H70.892
Other mastoiditis and
related conditions, left ear
H70.893
Other mastoiditis and
related conditions,
bilateral
H70.899
Other mastoiditis and
related conditions,
unspecified ear
Page 31 of 48
Medical Policy Number: UM.DIAG.01
H70.90
Unspecified mastoiditis,
unspecified ear
H70.91
Unspecified mastoiditis,
right ear
H70.92
Unspecified mastoiditis,
left ear
H70.93
Unspecified mastoiditis,
bilateral
H95.32
Accidental puncture and
laceration of the ear and
mastoid process during
other procedure
H95.41
Postprocedural hemorrhage
and hematoma of ear and
mastoid process following
a procedure on the ear and
mastoid process
H95.42
Postprocedural hemorrhage
and hematoma of ear and
mastoid process following
other procedure
H95.88
Other intraoperative
complications and
disorders of the ear and
mastoid process, not
elsewhere classified
H71.00
Cholesteatoma of attic,
unspecified ear
H95.89
Other postprocedural
complications and
disorders of the ear and
mastoid process, not
elsewhere classified
H71.01
Cholesteatoma of attic,
right ear
P11.3
Birth injury to facial nerve
H71.02
Cholesteatoma of attic,
left ear
Q16.9
Congenital malformation of
ear causing impairment of
hearing, unspecified
H71.03
Cholesteatoma of attic,
bilateral
Q85.02
Neurofibromatosis, type 2
H71.10
Cholesteatoma of
tympanum, unspecified ear
Q85.09
Other neurofibromatosis
H71.11
Cholesteatoma of
tympanum, right ear
R42
Dizziness and giddiness
Page 32 of 48
Medical Policy Number: UM.DIAG.01
S02.10xA
Unspecified fracture of
base of skull, initial
encounter for closed
fracture
H71.13
Cholesteatoma of
tympanum, bilateral
S02.10xB
Unspecified fracture of
base of skull, initial
encounter for open
fracture
H71.20
Cholesteatoma of mastoid,
unspecified ear
Type I occipital condyle
S02.110A fracture, initial encounter
for closed fracture
H71.21
Cholesteatoma of mastoid,
right ear
S02.110B
H71.22
Cholesteatoma of mastoid,
left ear
Type II occipital condyle
S02.111A fracture, initial encounter
for closed fracture
H71.23
Cholesteatoma of mastoid,
bilateral
S02.111B
H71.30
Diffuse cholesteatosis,
unspecified ear
Type III occipital condyle
S02.112A fracture, initial encounter
for closed fracture
H71.31
Diffuse cholesteatosis,
right ear
S02.112B
H71.32
Diffuse cholesteatosis, left
ear
Unspecified occipital
condyle fracture, initial
S02.113A
encounter for closed
fracture
H71.12
Cholesteatoma of
tympanum, left ear
H71.33
Diffuse cholesteatosis,
bilateral
Page 33 of 48
Medical Policy Number: UM.DIAG.01
S02.113B
Type I occipital condyle
fracture, initial encounter
for open fracture
Type II occipital condyle
fracture, initial encounter
for open fracture
Type III occipital condyle
fracture, initial encounter
for open fracture
Unspecified occipital
condyle fracture, initial
encounter for open
fracture
H71.90
Unspecified
cholesteatoma, unspecified
ear
Other fracture of occiput,
S02.118A initial encounter for closed
fracture
H71.91
Unspecified
cholesteatoma, right ear
S02.118B
H71.92
Unspecified
cholesteatoma, left ear
Unspecified fracture of
S02.119A occiput, initial encounter
for closed fracture
H71.93
Unspecified
cholesteatoma, bilateral
S02.119B
Unspecified fracture of
occiput, initial encounter
for open fracture
H72.00
Central perforation of
tympanic membrane,
unspecified ear
S02.19xA
Other fracture of base of
skull, initial encounter for
closed fracture
H72.01
Central perforation of
tympanic membrane, right
ear
S02.19xB
Other fracture of base of
skull, initial encounter for
open fracture
H72.02
Central perforation of
tympanic membrane, left
ear
S02.91xA
Unspecified fracture of
skull, initial encounter for
closed fracture
H72.03
Central perforation of
tympanic membrane,
bilateral
S02.91xB
Unspecified fracture of
skull, initial encounter for
open fracture
H72.10
Attic perforation of
tympanic membrane,
unspecified ear
S04.60xA
Injury of acoustic nerve,
unspecified side, initial
encounter
H72.11
Attic perforation of
tympanic membrane, right
ear
Injury of acoustic nerve,
S04.60xD unspecified side,
subsequent encounter
H72.12
Attic perforation of
tympanic membrane, left
ear
S04.60xS
Page 34 of 48
Medical Policy Number: UM.DIAG.01
Other fracture of occiput,
initial encounter for open
fracture
Injury of acoustic nerve,
unspecified side, sequela
H72.13
Attic perforation of
tympanic membrane,
bilateral
S04.61xA
H72.2x1
Other marginal
perforations of tympanic
membrane, right ear
Injury of acoustic nerve,
S04.61xD right side, subsequent
encounter
H72.2x2
Other marginal
perforations of tympanic
membrane, left ear
S04.61xS
Injury of acoustic nerve,
right side, sequela
H72.2x3
Other marginal
perforations of tympanic
membrane, bilateral
S04.62xA
Injury of acoustic nerve,
left side, initial encounter
H72.2x9
Other marginal
perforations of tympanic
membrane, unspecified ear
Injury of acoustic nerve,
S04.62xD left side, subsequent
encounter
H72.811
Multiple perforations of
tympanic membrane, right
ear
S04.62xS
H72.812
Multiple perforations of
tympanic membrane, left
ear
Contusion and laceration of
cerebrum, unspecified,
S06.330A without loss of
consciousness, initial
encounter
H72.813
Multiple perforations of
tympanic membrane,
bilateral
Contusion and laceration of
cerebrum, unspecified,
S06.331A with loss of consciousness
of 30 minutes or less,
initial encounter
H72.819
Multiple perforations of
tympanic membrane,
unspecified ear
Contusion and laceration of
cerebrum, unspecified,
S06.332A with loss of consciousness
of 31 minutes to 59
minutes, initial encounter
Page 35 of 48
Medical Policy Number: UM.DIAG.01
Injury of acoustic nerve,
right side, initial encounter
Injury of acoustic nerve,
left side, sequela
H72.821
Total perforations of
tympanic membrane, right
ear
Contusion and laceration of
cerebrum, unspecified,
S06.333A with loss of consciousness
of 1 hour to 5 hours 59
minutes, initial encounter
H72.822
Total perforations of
tympanic membrane, left
ear
Contusion and laceration of
cerebrum, unspecified,
S06.334A with loss of consciousness
of 6 hours to 24 hours,
initial encounter
Total perforations of
tympanic membrane,
bilateral
Contusion and laceration of
cerebrum, unspecified,
with loss of consciousness
S06.335A greater than 24 hours with
return to pre-existing
conscious level, initial
encounter
Total perforations of
tympanic membrane,
unspecified ear
Contusion and laceration of
cerebrum, unspecified,
with loss of consciousness
greater than 24 hours
S06.336A
without return to preexisting conscious level
with patient surviving,
initial encounter
Unspecified perforation of
tympanic membrane,
unspecified ear
Contusion and laceration of
cerebrum, unspecified,
with loss of consciousness
S06.337A of any duration with death
due to brain injury prior to
regaining consciousness,
initial encounter
H72.823
H72.829
H72.90
Page 36 of 48
Medical Policy Number: UM.DIAG.01
H72.91
Unspecified perforation of
tympanic membrane, right
ear
Contusion and laceration of
cerebrum, unspecified,
with loss of consciousness
S06.338A of any duration with death
due to other cause prior to
regaining consciousness,
initial encounter
H72.92
Unspecified perforation of
tympanic membrane, left
ear
Contusion and laceration of
cerebrum, unspecified,
S06.339A with loss of consciousness
of unspecified duration,
initial encounter
Unspecified perforation of
tympanic membrane,
bilateral
Traumatic hemorrhage of
cerebrum, unspecified,
S06.360A without loss of
consciousness, initial
encounter
Acute myringitis, right ear
Traumatic hemorrhage of
cerebrum, unspecified,
S06.361A with loss of consciousness
of 30 minutes or less,
initial encounter
Acute myringitis, left ear
Traumatic hemorrhage of
cerebrum, unspecified,
S06.362A with loss of consciousness
of 31 minutes to 59
minutes, initial encounter
Acute myringitis, bilateral
Traumatic hemorrhage of
cerebrum, unspecified,
S06.363A with loss of consciousness
of 1 hours to 5 hours 59
minutes, initial encounter
H72.93
H73.001
H73.002
H73.003
Page 37 of 48
Medical Policy Number: UM.DIAG.01
H73.009
H73.011
H73.012
H73.013
H73.019
Acute myringitis,
unspecified ear
Traumatic hemorrhage of
cerebrum, unspecified,
S06.364A with loss of consciousness
of 6 hours to 24 hours,
initial encounter
Bullous myringitis, right
ear
Traumatic hemorrhage of
cerebrum, unspecified,
with loss of consciousness
S06.365A greater than 24 hours with
return to pre-existing
conscious level, initial
encounter
Bullous myringitis, left ear
Traumatic hemorrhage of
cerebrum, unspecified,
with loss of consciousness
greater than 24 hours
S06.366A
without return to preexisting conscious level
with patient surviving,
initial encounter
Bullous myringitis, bilateral
Traumatic hemorrhage of
cerebrum, unspecified,
with loss of consciousness
S06.367A of any duration with death
due to brain injury prior to
regaining consciousness,
initial encounter
Bullous myringitis,
unspecified ear
Traumatic hemorrhage of
cerebrum, unspecified,
with loss of consciousness
S06.368A of any duration with death
due to other cause prior to
regaining consciousness,
initial encounter
Page 38 of 48
Medical Policy Number: UM.DIAG.01
H73.091
Other acute myringitis,
right ear
H73.092
Other acute myringitis, left
ear
H73.093
Other acute myringitis,
bilateral
H73.099
Other acute myringitis,
unspecified ear
H73.10
Chronic myringitis,
unspecified ear
H73.11
H73.12
Chronic myringitis, right
ear
Chronic myringitis, left ear
Page 39 of 48
Medical Policy Number: UM.DIAG.01
Traumatic hemorrhage of
cerebrum, unspecified,
S06.369A with loss of consciousness
of unspecified duration,
initial encounter
S06.4x0A
Epidural hemorrhage
without loss of
consciousness, initial
encounter
S06.4x1A
Epidural hemorrhage with
loss of consciousness of 30
minutes or less, initial
encounter
S06.4x2A
Epidural hemorrhage with
loss of consciousness of 31
minutes to 59 minutes,
initial encounter
S06.4x3A
Epidural hemorrhage with
loss of consciousness of 1
hour to 5 hours 59 minutes,
initial encounter
S06.4x4A
Epidural hemorrhage with
loss of consciousness of 6
hours to 24 hours, initial
encounter
S06.4x5A
Epidural hemorrhage with
loss of consciousness
greater than 24 hours with
return to pre-existing
conscious level, initial
encounter
H73.13
H73.20
Chronic myringitis,
bilateral
Unspecified myringitis,
unspecified ear
H73.21
Unspecified myringitis,
right ear
H73.22
Unspecified myringitis, left
ear
H73.23
Unspecified myringitis,
bilateral
H73.811
Atrophic flaccid tympanic
membrane, right ear
Page 40 of 48
Medical Policy Number: UM.DIAG.01
S06.4x6A
Epidural hemorrhage with
loss of consciousness
greater than 24 hours
without return to preexisting conscious level
with patient surviving,
initial encounter
S06.4x7A
Epidural hemorrhage with
loss of consciousness of any
duration with death due to
brain injury prior to
regaining consciousness,
initial encounter
S06.4x8A
Epidural hemorrhage with
loss of consciousness of any
duration with death due to
other causes prior to
regaining consciousness,
initial encounter
S06.4x9A
Epidural hemorrhage with
loss of consciousness of
unspecified duration,
initial encounter
S06.5x0A
Traumatic subdural
hemorrhage without loss of
consciousness, initial
encounter
S06.5x1A
Traumatic subdural
hemorrhage with loss of
consciousness of 30
minutes or less, initial
encounter
H73.812
Atrophic flaccid tympanic
membrane, left ear
H73.813
Atrophic flaccid tympanic
membrane, bilateral
H73.819
Atrophic flaccid tympanic
membrane, unspecified ear
H73.821
H73.822
H73.823
Atrophic nonflaccid
tympanic membrane, right
ear
Atrophic nonflaccid
tympanic membrane, left
ear
Atrophic nonflaccid
tympanic membrane,
bilateral
Page 41 of 48
Medical Policy Number: UM.DIAG.01
S06.5x2A
Traumatic subdural
hemorrhage with loss of
consciousness of 31
minutes to 59 minutes,
initial encounter
S06.5x3A
Traumatic subdural
hemorrhage with loss of
consciousness of 1 hour to
5 hours 59 minutes, initial
encounter
S06.5x4A
Traumatic subdural
hemorrhage with loss of
consciousness of 6 hours to
24 hours, initial encounter
S06.5x5A
Traumatic subdural
hemorrhage with loss of
consciousness greater than
24 hours with return to
pre-existing conscious
level, initial encounter
S06.5x6A
Traumatic subdural
hemorrhage with loss of
consciousness greater than
24 hours without return to
pre-existing conscious level
with patient surviving,
initial encounter
S06.5x7A
Traumatic subdural
hemorrhage with loss of
consciousness of any
duration with death due to
brain injury before
regaining consciousness,
initial encounter
H73.829
Atrophic nonflaccid
tympanic membrane,
unspecified ear
H73.891
Other specified disorders
of tympanic membrane,
right ear
H73.892
Other specified disorders
of tympanic membrane,
left ear
H73.893
Other specified disorders
of tympanic membrane,
bilateral
H73.899
Other specified disorders
of tympanic membrane,
unspecified ear
H73.90
Unspecified disorder of
tympanic membrane,
unspecified ear
H73.91
Unspecified disorder of
tympanic membrane, right
ear
Page 42 of 48
Medical Policy Number: UM.DIAG.01
S06.5x8A
Traumatic subdural
hemorrhage with loss of
consciousness of any
duration with death due to
other cause before
regaining consciousness,
initial encounter
S06.5x9A
Traumatic subdural
hemorrhage with loss of
consciousness of
unspecified duration,
initial encounter
S06.6x0A
Traumatic subarachnoid
hemorrhage without loss of
consciousness, initial
encounter
S06.6x1A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of 30
minutes or less, initial
encounter
S06.6x2A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of 31
minutes to 59 minutes,
initial encounter
S06.6x3A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of 1 hour to
5 hours 59 minutes, initial
encounter
S06.6x4A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of 6 hours to
24 hours, initial encounter
H73.92
H73.93
H74.01
H74.02
Unspecified disorder of
tympanic membrane, left
ear
Unspecified disorder of
tympanic membrane,
bilateral
Tympanosclerosis, right ear
Tympanosclerosis, left ear
S06.6x5A
Traumatic subarachnoid
hemorrhage with loss of
consciousness greater than
24 hours with return to
pre-existing conscious
level, initial encounter
S06.6x6A
Traumatic subarachnoid
hemorrhage with loss of
consciousness greater than
24 hours without return to
pre-existing conscious level
with patient surviving,
initial encounter
S06.6x7A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of any
duration with death due to
brain injury prior to
regaining consciousness,
initial encounter
S06.6x8A
Traumatic subarachnoid
hemorrhage with loss of
consciousness of any
duration with death due to
other cause prior to
regaining consciousness,
initial encounter
Traumatic subarachnoid
hemorrhage with loss of
consciousness of
unspecified duration,
initial encounter
H74.03
Tympanosclerosis, bilateral
S06.6x9A
H74.09
Tympanosclerosis,
unspecified ear
Other specified
intracranial injury without
S06.890A
loss of consciousness,
initial encounter
Page 43 of 48
Medical Policy Number: UM.DIAG.01
H74.11
H74.12
H74.13
H74.19
H74.20
H74.21
Adhesive right middle ear
disease
Other specified
intracranial injury with loss
S06.891A of consciousness of 30
minutes or less, initial
encounter
Adhesive left middle ear
disease
Other specified
intracranial injury with loss
S06.892A of consciousness of 31
minutes to 59 minutes,
initial encounter
Adhesive middle ear
disease, bilateral
Other specified
intracranial injury with loss
S06.893A of consciousness of 1 hour
to 5 hours 59 minutes,
initial encounter
Adhesive middle ear
disease, unspecified ear
Other specified
intracranial injury with loss
S06.894A of consciousness of 6 hours
to 24 hours, initial
encounter
Discontinuity and
dislocation of ear ossicles,
unspecified ear
Other specified
intracranial injury with loss
of consciousness greater
S06.895A
than 24 hours with return
to pre-existing conscious
level, initial encounter
Discontinuity and
dislocation of right ear
ossicles
Other specified
intracranial injury with loss
of consciousness greater
than 24 hours without
S06.896A
return to pre-existing
conscious level with
patient surviving, initial
encounter
Page 44 of 48
Medical Policy Number: UM.DIAG.01
H74.22
H74.23
H74.311
H74.312
H74.313
H74.319
H74.321
Discontinuity and
dislocation of left ear
ossicles
Other specified
intracranial injury with loss
of consciousness of any
S06.897A duration with death due to
brain injury prior to
regaining consciousness,
initial encounter
Discontinuity and
dislocation of ear ossicles,
bilateral
Other specified
intracranial injury with loss
of consciousness of any
S06.898A duration with death due to
other cause prior to
regaining consciousness,
initial encounter
Ankylosis of ear ossicles,
right ear
Other specified
intracranial injury with loss
S06.899A of consciousness of
unspecified duration,
initial encounter
Ankylosis of ear ossicles,
left ear
Ankylosis of ear ossicles,
bilateral
Ankylosis of ear ossicles,
unspecified ear
Partial loss of ear ossicles,
right ear
Page 45 of 48
Medical Policy Number: UM.DIAG.01
S06.9x0A
Unspecified intracranial
injury without loss of
consciousness, initial
encounter
S06.9x1A
Unspecified intracranial
injury with loss of
consciousness of 30
minutes or less, initial
encounter
S06.9x2A
Unspecified intracranial
injury with loss of
consciousness of 31
minutes to 59 minutes,
initial encounter
S06.9x4A
Unspecified intracranial
injury with loss of
consciousness of 6 hours to
24 hours, initial encounter
H74.322
H74.323
H74.329
Partial loss of ear ossicles,
left ear
Partial loss of ear ossicles,
bilateral
Partial loss of ear ossicles,
unspecified ear
S06.9x5A
Unspecified intracranial
injury with loss of
consciousness greater than
24 hours with return to
pre-existing conscious
level, initial encounter
S06.9x6A
Unspecified intracranial
injury with loss of
consciousness greater than
24 hours without return to
pre-existing conscious level
with patient surviving,
initial encounter
S06.9x7A
Unspecified intracranial
injury with loss of
consciousness of any
duration with death due to
brain injury prior to
regaining consciousness,
initial encounter
S06.9x8A
Unspecified intracranial
injury with loss of
consciousness of any
duration with death due to
other cause prior to
regaining consciousness,
initial encounter
H74.391
Other acquired
abnormalities of right ear
ossicles
H74.392
Other acquired
abnormalities of left ear
ossicles
S06.9x9A
Unspecified intracranial
injury with loss of
consciousness of
unspecified duration,
initial encounter
H74.393
Other acquired
abnormalities of ear
ossicles, bilateral
S09.10xA
Unspecified injury of
muscle and tendon of
head, initial encounter
Page 46 of 48
Medical Policy Number: UM.DIAG.01
H74.399
Other acquired
abnormalities of ear
ossicles, unspecified ear
Unspecified injury of
muscle and tendon of
S09.10xD
head, subsequent
encounter
H74.40
Polyp of middle ear,
unspecified ear
S09.10xS
Unspecified injury of
muscle and tendon of
head, sequela
H74.41
Polyp of right middle ear
S09.11xA
Strain of muscle and
tendon of head, initial
encounter
H74.42
Polyp of left middle ear
Strain of muscle and
S09.11xD tendon of head,
subsequent encounter
H74.43
Polyp of middle ear,
bilateral
S09.11xS
Strain of muscle and
tendon of head, sequela
H74.8x1
Other specified disorders
of right middle ear and
mastoid
S09.19xA
Other specified injury of
muscle and tendon of
head, initial encounter
H74.8x2
Other specified disorders
of left middle ear and
mastoid
Other specified injury of
muscle and tendon of
S09.19xD
head, subsequent
encounter
H74.8x3
Other specified disorders
of middle ear and mastoid,
bilateral
S09.19xS
Other specified injury of
muscle and tendon of
head, sequela
H74.8x9
Other specified disorders
of middle ear and mastoid,
unspecified ear
S09.8xxA
Other specified injuries of
head, initial encounter
H74.90
Unspecified disorder of
middle ear and mastoid,
unspecified ear
S09.8xxD
Other specified injuries of
head, subsequent
encounter
H74.91
Unspecified disorder of
right middle ear and
mastoid
S09.8xxS
Other specified injuries of
head, sequela
H74.92
Unspecified disorder of left
middle ear and mastoid
S09.90xA
Unspecified injury of head,
initial encounter
Page 47 of 48
Medical Policy Number: UM.DIAG.01
Unspecified disorder of
middle ear and mastoid,
bilateral
S09.90xD
Unspecified injury of head,
subsequent encounter
S09.90xS
Unspecified injury of head,
sequela
Z00.121
Encounter for routine child
health examination with
abnormal findings
Z00.129
Encounter for routine child
health examination
without abnormal findings
Z01.110
Encounter for hearing
examination following
failed hearing screening
H75.80
Other specified disorders
of middle ear and mastoid
in diseases classified
elsewhere, unspecified ear
Z48.810
Encounter for surgical
aftercare following surgery
on the sense organs
H75.81
Other specified disorders
of right middle ear and
mastoid in diseases
classified elsewhere
Z85.841
Personal history of
malignant neoplasm of
brain
Z97.4
Presence of external
hearing-aid
H74.93
H75.00
H75.01
H75.02
H75.03
Mastoiditis in infectious
and parasitic diseases
classified elsewhere,
unspecified ear
Mastoiditis in infectious
and parasitic diseases
classified elsewhere, right
ear
Mastoiditis in infectious
and parasitic diseases
classified elsewhere, left
ear
Mastoiditis in infectious
and parasitic diseases
classified elsewhere,
bilateral
100715RLG
Page 48 of 48
Medical Policy Number: UM.DIAG.01