CurrentAmbetter NevadaPolicy CP.MP.93

Bone-Anchored Hearing Aid (BAHA) Coverage Criteria

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Medical necessity and coverage criteria for implantation, replacement, and external components of bone-anchored hearing aids for members/enrollees of the health plan.

Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aid (BAHA) Coverage Criteria

Policy CodePolicy CP.MP.93

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit supporting audiometric data and indication per the medical necessity criteria.

SourceLink

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CurrentAmbetter NevadaPolicy CP.MP.93

Bone-Anchored Hearing Aid (BAHA) Coverage Criteria

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Sign up for Ambetter Nevada Policy CP.MP.93 alerts

Get alerted when Policy CP.MP.93 changes without checking for updates manually.

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Medical necessity and coverage criteria for implantation, replacement, and external components of bone-anchored hearing aids for members/enrollees of the health plan.

Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aid (BAHA) Coverage Criteria

Policy CodePolicy CP.MP.93

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit supporting audiometric data and indication per the medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥5min age (implantable)

<5head band option

≥60%min speech score

≥5yprocessor age for replace

Coverage Criteria for Bone-Anchored Hearing Aids (BAHA)

Initial implantation candidacy

Covered when ALL of the following are met:

Primary candidacy: A. Implantable device for age ≥ five years; or head band device for age < five years or medically unable to have an implant; B. Unilateral or bilateral conductive and/or mixed hearing loss or unilateral sensorineural hearing loss where the condition prevents restoration of hearing using a conventional air-conduction hearing aid; C. Pure tone average bone conduction threshold (0.5,1,2,3 kHz) is consistent with the FDA indications for the requested device and an unaided speech discrimination score ≥ 60%; D. For bilateral BAHA, mean maximum difference < 10 dB between right and left bone conduction thresholds; E. For unilateral deafness, hearing ear bone conduction threshold < 20 dB; F. One of the following indications: (1) Congenital or surgically induced malformations of the ear canal such that it does not exist or cannot accommodate a standard air-conduction hearing aid (provided that the nerve is functional); (2) Chronic infection or dermatitis of the middle or outer ear exacerbated by a standard air-conduction hearing aid; (3) Allergic reactions to standard air-conduction hearing aids; (4) Unilateral deafness after removal of an acoustic neuroma, trauma, viral or vascular insult, or idiopathic causes; (5) Tumors of the external canal and/or tympanic cavity; (6) Air-conduction hearing aid ineffective due to large conductive hearing loss (inadequate gain, uncomfortable occlusion, feedback).see node text

All elements A–F must be met as stated.

Replacement of BAHA/device components

Replacement is considered medically necessary when ANY of the following are met:

Replacement criteria: A. Existing device(s) is no longer functional and cannot be repaired; B. A change in condition makes the existing unit(s) inadequate for the hearing-related activities of daily living and improvement is expected with replacement; C. The current sound processor is at least five years old.see node text

Any one condition suffices.

Not medically necessary: elective upgrades

Not medically necessary upgrade: Replacement or upgrade of an existing, properly functioning BAHA and/or its external components is considered not medically necessary when requested only for convenience or to simply upgrade to a newer technology before the timeframe noted in section II.N/A

Policy states this is not medically necessary.

Upgrades of a properly functioning bone-anchored hearing aid (BAHA) or its external components requested solely for convenience or to obtain newer technology are not supported unless the replacement meets the medical necessity conditions described elsewhere in this policy. Specifically, requests to replace functioning devices for the purpose of accessing newer features, cosmetic changes, or nonclinical preferences do not meet the criteria for coverage.

Replacement or upgrade of an existing, properly functioning BAHA and/or its external sound processor is considered not medically necessary when requested only for convenience or to upgrade to newer technology prior to the replacement conditions in section II. Coverage for replacement is limited to situations where the device is nonfunctional and unrepairable, a change in clinical condition makes the existing unit inadequate for activities of daily living, or the sound processor has reached the age threshold specified in section II.

Coding and Key Clinical Thresholds

Covered CPT CodesCPTCovered

69710	Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone.
69711	Removal or repair of electromagnetic bone conduction hearing device in temporal bone.
69714	Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69716	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69717	Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69719	Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69726	Removal, entire osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69727	Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69728	Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex.
69729	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex.

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Covered HCPCS CodesHCPCSCovered

L8690	Auditory osseointegrated device, includes all internal and external components.
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each.
L8692	Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment.
L8693	Auditory osseointegrated device abutment, any length, replacement only.
L8694	Auditory osseointegrated device, transducer/actuator, replacement only, each.

inv-08: Unaided speech discrimination score — threshold value

ThresholdUnaided speech discrimination score ≥ 60%

DefinitionPercentage score measuring speech recognition without amplification

Use in criteriaRequired as part of initial implantation candidacy (see policy I.C)

inv-09: Interaural bone conduction difference for bilateral BAHA — mean maximum difference criterion

Mean maximum difference criterionMean maximum interaural bone conduction difference < 10 dB

ApplicationRequired for bilateral BAHA candidacy (comparison of right and left bone conduction thresholds)

Actions Required by Providers

Prior Authorization

Prior Authorization Required

Prior authorization is required for implantation and replacement procedures and for external components. Submit supporting audiometric data and documentation with the request.

Affected CPT: 69710, 69711, 69714, 69716, 69717, 69719, 69726, 69727, 69728, 69729, 69730
Affected HCPCS: L8690, L8691, L8692, L8693, L8694

Prior Authorization

Replacement / Upgrade Conditions

Replacement of external components (external sound processor) or entire BAHA is allowed when the existing device is nonfunctional and cannot be repaired, when a change in the member’s condition renders the current unit inadequate and improvement is expected with replacement, or when the current sound processor is at least five years old. Replacement or upgrade is not medically necessary if requested solely for convenience or to obtain newer technology before these conditions are met.

Replacement allowed if device nonfunctional/unrepairable
Replacement allowed for change in condition with expected improvement

Background

Bone-anchored hearing aids (BAHAs) transmit sound via bone conduction to the inner ear and are used when conventional air-conduction hearing aids cannot adequately restore hearing. Indications for BAHA systems include conductive or mixed hearing loss and single-sided sensorineural deafness when anatomical, medical, or functional issues prevent use of standard air-conduction devices. Implantable BAHA components are typically considered when clinically appropriate; replacements are reserved for devices that are nonfunctional, when patient condition changes render the current unit inadequate, or when the external sound processor meets the policy’s age-based replacement threshold.

Definitions

inv-17: BAHA — definition of bone-anchored hearing aid (implantable vs external)

DefinitionBone-anchored hearing aid (BAHA) — an implantable or external bone conduction hearing system that transmits sound via the skull to the inner ear

Implantable BAHAUses a titanium osseointegrated implant with an abutment for attaching an external processor

External/headband BAHAExternal sound processor worn without osseointegration (e.g., headband) used for younger children or when implant is not feasible

IndicationsUsed for conductive, mixed, or single-sided sensorineural hearing loss when conventional air-conduction hearing aids cannot restore hearing

inv-18: Unaided speech discrimination score — definition and required threshold

DefinitionUnaided speech discrimination score — percentage score measuring speech recognition without amplification

Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aid (BAHA) Coverage Criteria

Policy CodePolicy CP.MP.93

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit supporting audiometric data and indication per the medical necessity criteria.

SourceLink

On This Page

MeasurementBased on bone conduction thresholds at standard frequencies (0.5, 1, 2, 3 kHz)

inv-10: Hearing ear bone conduction threshold for unilateral deafness — threshold value

ThresholdHearing ear bone conduction threshold < 20 dB

ContextRequired for unilateral deafness candidacy (hearing ear must meet this threshold)

MeasurementBone conduction threshold measured at standard audiometric frequencies

inv-11: Sound processor age for replacement — processor age criterion

Processor age criterionCurrent sound processor is at least five years old

Replacement rationaleOne of the conditions that makes replacement medically necessary

Policy locationListed under replacement criteria (Policy II.C)

Replacement allowed when sound processor ≥ 5 years old

Not medically necessary for convenience or premature technology upgrades

Documentation Required

Required Clinical Documentation

Document the member’s age and the type of device requested (implantable device vs headband device). Include comprehensive audiometric results: pure tone average bone conduction thresholds (0.5, 1, 2, and 3 kHz), speech discrimination scores (unaided, must be ≥ 60% when applicable), and comparison of right vs left bone conduction thresholds (for bilateral BAHA mean maximum difference < 10 dB). Provide evidence that conventional air-conduction hearing aids are ineffective or cannot be used (e.g., canal atresia, chronic infection, dermatitis, allergic reaction, tumor, large conductive loss). Include prior repair attempts and supporting clinical rationale for replacement or upgrade.

Patient age and device type requested
Pure tone average bone conduction thresholds at 0.5, 1, 2, and 3 kHz
Unaided speech discrimination score (document value)
For bilateral BAHA: mean maximum difference < 10 dB between ears
Evidence conventional air-conduction aid ineffective or contraindicated
Description of repair attempts if device previously malfunctioned

Denial Risk

Denial Risk for Unmet Criteria

Requests that do not meet the listed medical necessity criteria (for example: age requirements, hearing loss type/thresholds, speech discrimination scores, device-specific FDA indications, or lack of supporting audiometric documentation) are at risk for denial.

Denial risk if age criteria not met (implantable device for ≥ 5 years; headband for < 5 years)
Denial risk if pure tone average bone conduction thresholds inconsistent with device FDA indications
Denial risk if unaided speech discrimination < 60% when required
Denial risk if lack of documentation showing air-conduction aid ineffective or contraindicated

Required thresholdScore must be ≥ 60% for device candidacy

Role in policyPart of initial implantation criteria (Policy I.C) alongside pure tone average bone conduction thresholds