Document audiologic testing and reason air-conduction aids are contraindicated

Providers must document the member's age and detailed audiologic testing showing bone-conduction pure-tone average (PTA) and explain why a conventional air-conduction hearing aid is contraindicated. Required documentation should include age (implantation generally requires age ≥5), pre-implantation bone-conduction PTA, comparison/symmetry data for bilateral candidacy, and a clear clinical reason air-conduction aids cannot restore hearing (examples: congenital aural atresia, dermatitis/hypersensitivity to ear molds, otosclerosis when stapedectomy is not possible, severe chronic otitis, tumors of the external ear/tympanic cavity).

• Age: document member age (implantation generally for age ≥5).
• Bone-conduction PTA: pre-implantation BC PTA measured at 0.5, 1, 2, and 3 kHz.
• Symmetry criteria: include side-to-side BC comparison when bilateral fitting is considered (device-specific thresholds apply).
• Clinical reason: state why an air-conduction hearing aid is contraindicated (e.g., congenital/surgically induced malformation, dermatitis/hypersensitivity to ear molds, otosclerosis when stapedectomy is not possible, severe chronic external otitis/otitis media, tumors).

Verify device-specific audiometric thresholds

Document device-specific audiometric thresholds using bone-conduction PTA measured at the frequencies required by the device indication. Verify thresholds at 0.5, 1, 2 and 3 kHz and confirm that the BC PTA meets the processor/system-specific cutoff (device-dependent thresholds vary by model and power).

• Measure and record BC PTA at 0.5, 1, 2, and 3 kHz.
• Compare measured BC PTA to device-specific thresholds (e.g., Bonebridge ≤45 dB HL; Baha SoundArc: ≤45, ≤55, or ≤65 dB HL depending on processor model; Adhear ≤25 dB HL).
• Document which device/processor model's threshold criteria were used for the determination.

Assess candidacy for bilateral fitting

When assessing candidacy for bilateral fitting, document that bilateral bone-conduction thresholds are symmetric per policy definitions. Record side-to-side BC differences and confirm they meet the symmetric criteria appropriate for the device.

• Document symmetry as either ≤10 dB average difference between ears (specified frequencies) OR <15 dB difference at individual frequencies (device-specific frequency sets apply).

Document single-sided deafness (SSD) criteria

For single-sided deafness (SSD) indications, document the air-conduction pure tone average (AC PTA) of the better-hearing ear. The normal-hearing ear must meet the policy definition when required by the device: AC PTA ≤20 dB HL measured at 0.5, 1, 2, and 3 kHz.

• Record AC PTA of the contralateral (better) ear at 0.5, 1, 2 and 3 kHz and document it is ≤20 dB HL when SSD criteria are required.

Medical necessity review for accessories/upgrades

A separate assessment is required for medical necessity of recommended accessories and upgrades. Providers should document the member's current condition, how the current device performs, and the expected clinically significant benefit from the accessory or upgrade to support prior authorization.

• Perform and document a separate clinical justification for accessories/upgrades.
• Consider the member's current functional status and whether the upgrade will provide a clinically significant improvement.

Use applicable CPT/HCPCS/ICD-10 codes

Use the applicable CPT and HCPCS procedure and supply codes when selection criteria are met and include diagnosis codes that justify the medical indication. Report implantation, removal, revision, programming, and replacement with the listed codes.

• Key CPT/HCPCS: 69710, 69714, 69716, 92622, L8690, L8692.
• Include appropriate ICD-10 diagnosis codes that justify the indication (e.g., conductive/mixed hearing loss, congenital malformation, chronic otitis, otosclerosis as applicable).

Requests for non-covered devices/indications

Requests for certain devices or indications may be denied as experimental/investigational or not covered. Documented exceptions are limited; providers should be aware intra-oral devices (e.g., SoundBite), Otomag Alpha 1(M) and some partially implantable systems are considered experimental or not covered for broad indications and may be denied unless specific covered exceptions apply. Plans that exclude hearing aids do not cover non-osseointegrated devices except limited pediatric bridge uses.

• Intra-oral devices (SoundBite) are considered experimental/investigational and not routinely covered.
• Otomag Alpha 1(M) and other partially implantable systems have insufficient evidence and may be considered not covered.
• Non-osseointegrated devices (Soft Band, SoundArc, Adhear) are not covered under plans that exclude hearing aids except as a bridge for children <5 years when meeting criteria.

Policy review dates and effective date

Document the policy's effective date and review schedule in the patient's record and cite the current policy version when submitting requests. Providers should reference the most recent policy for coverage criteria.

• Effective date: 2000-03-09
• Last review: 2024-02-16
• Next review: 2024-04-25
• Reference the current policy version when preparing documentation or prior authorization requests.