Hearing Aids
Policy governing medical necessity, coverage, and exclusions for air conduction, implantable, and semi-implantable hearing aids for Aetna members and guidance for plans that do not exclude hearing aids.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medically necessary indications
Aetna considers the following medically necessary:
Air conduction hearing aids
- Hearing threshold criteria: Hearing thresholds >= 40 dB HL at 500, 1000, 2000, 3000, or 4000 Hz; OR hearing thresholds >= 26 dB HL at three of these frequencies.
- Speech recognition criterion: Speech recognition < 94%.
Examples: Esteem, Carina, Maxum, Vibrant Soundbridge
Applies for plans that do not exclude hearing aids
Experimental and investigational
Procedures considered experimental and investigational:
Experimental / Investigational
- Balance indication: Air conduction hearing aids for improvement of balance.
- Other indications: Hearing aids and semi-implantable hearing aids for all other indications, including improvement of depression and cognitive decline in the elderly.
- Device technology: Use of a free-floating piezoelectric microphone in an implantable hearing aid.
Most Aetna benefit plans exclude coverage of hearing aids. Any applicable benefit plan exclusions and limitations for coverage of hearing aids apply to air conduction, implantable, and semi-implantable hearing aids. Providers and billing teams should verify the member’s benefit plan for applicable exclusions or limitations before submitting claims, as claims may be denied when the member’s plan does not cover hearing aids.
Systematic reviews of tinnitus treatments that included hearing aids, sound generators, and combination devices found no clear evidence that sound therapy is superior to waiting-list control, placebo, or education/information only. The evidence was generally low quality and limited by risk of bias and sparse data, which limits claims that sound therapy provides superior clinical benefit for tinnitus.
Use of hearing aids to treat non-auditory conditions such as major depressive disorder, vestibular/vertiginous disorders, or age‑related cognitive decline is not supported as covered indications in this policy. The CPB lists ICD-10 codes for these conditions as not covered for the indications described; clinicians should exercise caution and document that the primary indication for a hearing aid is auditory impairment that meets the medical necessity criteria if coverage is being pursued.
Evidence comparing bilateral versus unilateral hearing aids for adults with bilateral hearing impairment is limited and of very low quality. Small, heterogeneous randomized trials with older-generation devices produced inconsistent patient preference results and did not provide robust data on quality‑of‑life or audiometric outcomes. The CPB therefore notes insufficient evidence to conclude a clear superiority of bilateral over unilateral fitting for coverage purposes, and this should be considered when documenting medical necessity and device selection.
Coding and Clinical Thresholds
| H90.3 - H90.8 | Sensorineural hearing loss and mixed conductive and sensorineural hearing loss. |
| Q16.1 | Congenital absence, atresia and stricture of auditory canal (external). |
| F32.0 - F32.9 | Major depressive disorder, single episode. |
| F33.0 - F33.9 | Major depressive disorder, recurrent. |
| H81.311 - H81.399 | Other peripheral vertigo. |
| H81.8X1 - H81.8X9 | Other disorders of vestibular function. |
| H81.90 - H81.93 | Unspecified disorder of vestibular function. |
| H82.1 - H82.9 | Vertiginous syndromes in diseases classified elsewhere. |
| R41.81 | Age-related cognitive decline. |
| No codes listed |
Provider Responsibilities and Billing Guidance
Billing guidance & documentation
Coverage of HCPCS and ICD-10 codes in this policy is contingent on meeting the selection/medical necessity criteria. Providers should verify member benefits and document medical necessity (pre- and post-operative thresholds, Merchant grade, surgical outcomes, and relevant audiometric testing) when submitting claims.
- Verify member benefit plan for hearing aid coverage — many Aetna plans exclude hearing aids and claims may be denied if excluded.
- Document pre- and post-operative audiometric thresholds, Merchant grade, and surgical outcomes as captured in cited studies (e.g., Geerse et al. 2020).
Prior authorization not specified
This section does not specify any payer-level prior authorization requirements. Providers should still check the member’s benefit plan and any applicable medical management rules before scheduling services.
- No prior authorization requirement is stated in this policy section.
- Confirm any prior authorization requirements with the member’s plan or via normal benefit verification processes.
Prior authorization — provider action
Although prior authorization is not specified here, providers should be prepared to obtain authorization if required by the member’s benefit plan and to supply supporting documentation for medical necessity.
- If the benefit plan requires prior authorization, include audiometric test results, history of hearing aid use/intolerance (for implantable options), and surgical notes.
- For Vibrant Soundbridge or other implantable devices, document that appropriately fit hearing aids were tried prior to implantation when applicable.
Step therapy not addressed
Step therapy or step-wise treatment requirements are not addressed in this policy section. There are no described step therapy requirements for hearing aids or implantable devices within these background and coding blocks.
- No step-therapy policies or staged treatment prerequisites are described here.
- Providers should follow clinical best practices and verify any plan-specific step therapy separately.
FDA note — Vibrant Soundbridge (alternative to hearing aids)
The FDA classifies the Vibrant Soundbridge as a surgically implanted hearing device and notes it may be used as an alternative to traditional hearing aids; adults choosing this device should have already tried appropriately fit hearing aids.
- Document prior use and intolerance or inadequacy of conventional hearing aids when considering implantable/semi-implantable devices.
- Include HCPCS code V5095 when billing for the Vibrant Soundbridge where selection criteria are met.
Denial risk — benefit exclusions
Claims may be denied when applicable benefit plans exclude hearing aids. Verify member coverage before ordering or providing devices and include documentation to support medical necessity.
- Most Aetna benefit plans exclude coverage of hearing aids — check benefit plan descriptions.
- If excluded, submit claims cautiously; denials are possible when benefits do not cover hearing aids, implantable or semi-implantable devices.
Policy history and review dates
Policy history and review dates are documented for provider reference; use these dates for currency checks and to reference the most recent policy version.
- Providers should reference the policy history when citing coverage rationale or when preparing appeals.
- Policy updates and review history are available via the policy review links.
Not applicable content — no additional payer triggers
Not applicable / no explicit denial-trigger content is present in the clinical background and study summaries — this part of the section does not define new billing denial triggers beyond benefit exclusions and lack of medical necessity documentation.
- No additional payer-level denial triggers, prior auth code lists, or step therapy rules are defined in these background chunks.
- Providers should rely on documented selection criteria, benefit verification, and standard billing guidance.
Background and Context
Implantable and semi-implantable middle ear hearing devices (for example, the Vibrant Soundbridge, the Esteem totally implantable system, and devices such as the Carina) are alternatives to conventional hearing aids for selected patients with moderate‑to‑severe sensorineural, conductive, or mixed hearing loss. Indications commonly include patients who cannot tolerate ear molds (for example, congenital external auditory canal atresia or severe chronic otitis externa) or those for whom conventional amplification is not feasible. Clinical outcomes vary by device and population, and the policy limits coverage of these devices to members who meet the specific medical necessity criteria described in the policy.
Device Definitions
Policy History and Review Dates
Policy became effective on May 3, 2002.
Policy was last reviewed on September 12, 2023.
Next scheduled policy review is July 11, 2024.
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