CurrentAmbetter NevadaPolicy AR.CP.MP.93

Bone-Anchored Hearing Aids (Arkansas)

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This policy governs medical necessity and replacement coverage for bone-anchored hearing aids, including implantable devices, headband devices, implants, abutments, and external sound processors for specified conductive, mixed, or single-sided sensorineural hearing loss.

Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aids (Arkansas)

Policy CodePolicy AR.CP.MP.93

Change TypeNo material change

Effective DateN/A

Last ReviewJul 28, 2021

Next Review DateN/A

Key ActionDocument the member’s age, requested device type, audiologic findings, qualifying indication, and replacement criteria when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age ≥5 yearsImplantable device eligibility

≤70 dBHLBone-conduction threshold

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CurrentAmbetter NevadaPolicy AR.CP.MP.93

Bone-Anchored Hearing Aids (Arkansas)

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

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Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aids (Arkansas)

Policy CodePolicy AR.CP.MP.93

Change TypeNo material change

Effective DateN/A

Last ReviewJul 28, 2021

Next Review DateN/A

Key ActionDocument the member’s age, requested device type, audiologic findings, qualifying indication, and replacement criteria when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Age ≥5 yearsImplantable device eligibility

≤70 dBHLBone-conduction threshold

Speech discrimination

<10 dBBilateral threshold difference

5 / 2 yearsProcessor replacement interval

6 CPT / 4 HCPCSProcedure and device codes

Medical Necessity and Replacement Coverage

Medically necessary initial therapy and replacement

Covered as medically necessary when all of the following are met.

Initial BAHA medical necessity

Device type and age: Implantable device for age ≥ 5 years; or headband device for age < 5 years; or headband device for a member medically unable to have an implant
Hearing-loss type: Single-sided or bilateral conductive hearing loss; or single-sided or bilateral mixed conductive and sensorineural hearing loss; or single-sided sensorineural hearing loss
Audiologic thresholds: Pure-tone average bone-conduction threshold measured at 0.5, 1, 2, and 3 kHz is ≤ 70 dBHL and unaided speech discrimination score is not worse than 60%≤ 70 dBHL; speech discrimination not worse than 60%
Laterality-specific audiologic requirement: For bilateral BAHA, mean maximum difference between right and left bone-conduction thresholds is <10 dB; or for single-sided deafness, the hearing ear has a bone-conduction threshold of 20 dB<10 dB bilateral difference; 20 dB hearing-ear threshold for single-sided deafness
Apply the applicable branch based on requested laterality.
Qualifying indication: Congenital or surgically induced ear-canal malformation prevents use of a standard air-conduction hearing aid; chronic middle- or outer-ear infection or dermatitis is exacerbated by a standard air-conduction aid; allergic reaction to a standard air-conduction aid; single-sided deafness after acoustic neuroma removal, trauma, or viral or vascular insult; tumor of the external canal and/or tympanic cavity; or air-conduction aid is ineffective due to large conductive hearing loss, inadequate gain, uncomfortable occlusion, or feedback
At least one listed indication is required.

"operator":"all","label":"Replacement of BAHA or external component","text":"Replacement is medically necessary when at least one replacement condition is present","children":[{"operator":"any","label":"Replacement condition","text":"Existing device is no longer functional and cannot be repaired; or a change in the member's condition makes the existing unit inadequate for hearing-related activities of daily living and improvement is expected with replacement; or the sound processor is at least 5 years old for a member without craniofacial anomaly or at least 2 years old for a member with a craniofacial anomaly diagnosis","threshold":"5 years without craniofacial anomaly; 2 years with craniofacial anomaly","children":[]}]}

"operator":"any","label":"Headband device pathway","text":"A headband device may be used for a member younger than 5 years or for a member medically unable to have an implant","threshold":"Age <5 years or medical inability to undergo implant","note":"This is a device-selection branch within initial medical necessity criteria.","children":[]}

Unlisted indications

Not medically necessary.

Other indications: BAHA requested for any indication not listed in the policy is considered not medically necessary because effectiveness has not been established.

Premature replacement or upgrade

Not medically necessary.

Convenience or technology upgrade: Replacement or upgrade of an existing properly functioning BAHA or external sound processor requested only for convenience or to obtain newer technology before the applicable replacement timeframe is not medically necessary.Before 5 years without craniofacial anomaly or before 2 years with craniofacial anomaly

A properly functioning BAHA or external sound processor is not medically necessary when replacement or upgrade is requested only for convenience or to obtain newer technology before the applicable replacement timeframe.

BAHAs requested for indications other than the policy’s listed qualifying indications are not medically necessary because effectiveness has not been established.

Replacement of a functioning BAHA or external sound processor is not medically necessary when requested solely for convenience or a technology upgrade before the applicable interval: 5 years for members without a craniofacial anomaly and 2 years for members with a craniofacial anomaly. Replacement may otherwise be considered when the existing device is nonfunctional and irreparable, the member’s condition makes it inadequate for hearing-related activities of daily living with expected improvement from replacement, or the applicable processor-age threshold is met.

Codes and Coverage Thresholds

CPT CodesCPT

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, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
69715	Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
69717	Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
69718	Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy

HCPCS CodesHCPCS

L8690	Auditory osseointegrated device, includes all internal and external components
L8691	Auditory osseointegrated device, external sound processor, replacement
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

ICD-10-CM Diagnosis CodesICD-10

H60.00-H62.8X9	Diseases of external ear
H61.001-H61.039	Chondritis and perichondritis of external ear
H61.111-H61.119	Acquired deformity of pinna
H65.20-H65.23	Chronic serous otitis media
H65.30-H65.33	Chronic mucoid otitis media
H65.411-H65.499	Other chronic non-suppurative otitis media
H71.00-H71.93	Cholesteatoma of middle ear
H80.00-H80.93	Otosclerosis
H90.0-H90.8	Conductive and sensorineural hearing loss
H91.01-H91.93	Other and unspecified hearing loss

1–10 of 11

1/2

Implantable device age

Minimum age≥ 5 years

Applies toImplantable bone-anchored hearing aid device

Alternative for members younger than 5A headband device may be used for age < 5 years or when medically unable to have an implant

Pure-tone average bone-conduction threshold

Maximum pure-tone average≤ 70 dBHL

Measurement frequencies0.5, 1, 2, and 3 kHz

Documentation and Denial Risks

Documentation Required

Age and Device Type

Document the member’s age and the requested BAHA device type. An implantable device is appropriate for members age 5 years or older; use a head-band device for members younger than 5 years or for members medically unable to undergo implantation.

Member age
Requested device type: implantable or head-band
If a head-band device is requested for a member age 5 years or older, document the medical inability to undergo implantation.

Documentation Required

Audiologic Findings

Document the hearing-loss type and laterality, along with the required audiologic findings. Pure-tone average bone-conduction thresholds must be measured at 0.5, 1, 2, and 3 kHz and must be ≤70 dBHL, with an unaided speech discrimination score not worse than 60%.

Single-sided or bilateral conductive hearing loss; single-sided or bilateral mixed conductive and sensorineural hearing loss; or single-sided sensorineural hearing loss
Pure-tone average bone-conduction threshold: ≤70 dBHL

Clinical Context

A bone-anchored hearing aid (BAHA) transmits sound through bone directly to the inner ear, bypassing the external and middle ear. It may be used for conductive or mixed conductive and sensorineural hearing loss, as well as single-sided profound sensorineural hearing loss, particularly when a conventional air-conduction hearing aid cannot provide adequate functional improvement or causes complications such as canal irritation, infection, feedback, inadequate gain, or uncomfortable occlusion. Implantable devices require sufficient bone for osseointegration; headband devices may be used for younger children or members unable to undergo implantation.

Key Terms

Bone-anchored hearing aid (BAHA)

FunctionTransmits sound through the skull bone to the inner ear

Implantable componentsA titanium skull implant, an abutment, and a removable bone-conduction hearing aid or processor

External configurationMay be externally attached by a headband or other means

Conductive or mixed conductive and sensorineural hearing loss

Primary impairmentImpairment in sound transmission through the external or middle ear

Conductive lossMay involve conductive hearing loss alone

Mixed loss

Policy Summary

PayerAmbetter Nevada

PolicyBone-Anchored Hearing Aids (Arkansas)

Policy CodePolicy AR.CP.MP.93

Change TypeNo material change

Effective DateN/A

Last ReviewJul 28, 2021

Next Review DateN/A

Key ActionDocument the member’s age, requested device type, audiologic findings, qualifying indication, and replacement criteria when applicable.

SourceLink

On This Page

Bone-conduction threshold

Unaided speech discrimination score

Required scoreNot worse than 60%

AssessmentUnaided speech discrimination score

Coverage applicationRequired as part of the audiologic threshold criteria

Bilateral BAHA interaural bone-conduction difference

Maximum mean difference<10 dB

ComparisonRight bone-conduction threshold versus left bone-conduction threshold

Applies toBilateral BAHA requests

Single-sided deafness hearing-ear threshold

Required thresholdBone-conduction threshold of 20 dB

Ear assessedThe hearing ear

Applies toSingle-sided deafness requests

External sound processor replacement without craniofacial anomaly

Minimum processor ageAt least 5 years old

Member statusMember without craniofacial anomaly

Replacement itemCurrent external sound processor

External sound processor replacement with craniofacial anomaly

Minimum processor ageAt least 2 years old

Member statusMember with a craniofacial anomaly diagnosis

Replacement itemCurrent external sound processor

Unaided speech discrimination score: not worse than 60%

Documentation Required

Laterality-Specific Thresholds

For bilateral BAHA, document the mean maximum interaural difference between right and left bone-conduction thresholds. For single-sided deafness, document that the hearing ear has a bone-conduction threshold of 20 dB.

Bilateral BAHA: mean maximum right-versus-left bone-conduction threshold difference <10 dB
Single-sided deafness: hearing-ear bone-conduction threshold of 20 dB

Documentation Required

Qualifying Clinical Indication

Document at least one qualifying clinical indication supporting the BAHA request.

Congenital or surgically induced ear-canal malformation in which the canal is absent or cannot accommodate a standard air-conduction hearing aid
Chronic middle- or outer-ear infection or dermatitis exacerbated by a standard air-conduction hearing aid
Allergic reaction to a standard air-conduction hearing aid
Single-sided deafness following acoustic-neuroma removal, trauma, or viral or vascular insult
Tumor of the external canal and/or tympanic cavity
Air-conduction hearing aid ineffective because of large conductive hearing loss, including inadequate gain, uncomfortable occlusion, or feedback effects

Documentation Required

Replacement Documentation

For replacement of a BAHA or external sound processor, document the applicable replacement basis and the expected benefit. A processor replacement may also be supported when the current processor has reached the applicable age-based timeframe.

Existing device is no longer functional and cannot be repaired
A change in the member’s condition makes the existing unit inadequate for hearing-related activities of daily living, and improvement is expected with replacement
Current sound processor is at least 5 years old for a member without a craniofacial anomaly
Current sound processor is at least 2 years old for a member with a craniofacial anomaly diagnosis

Denial Risk

Initial-Therapy Criteria Not Met

BAHA treatment is not medically necessary when the required eligibility, hearing-loss, audiologic, laterality-specific, or qualifying-indication criteria are not met. Confirm and document all applicable initial-therapy criteria before submission.

Required age and device-type criteria must be met
A qualifying hearing-loss type and laterality must be documented
Bone-conduction and speech-discrimination thresholds must meet policy limits
Applicable bilateral or single-sided-deafness threshold findings must be documented
At least one qualifying clinical indication must be present

Denial Risk

Unlisted Indication

BAHAs requested for indications outside the policy’s listed qualifying indications are considered not medically necessary because effectiveness has not been established.

Do not submit an unlisted indication without documentation that it fits one of the policy’s qualifying indications.

Denial Risk

Convenience or Premature Technology Upgrade

Replacement or upgrade of a properly functioning BAHA or external sound processor is not medically necessary when requested only for convenience or to obtain newer technology before the applicable replacement timeframe.

The existing device or processor must have a documented qualifying replacement basis
Do not request a premature technology upgrade solely for convenience or access to newer technology
Apply the 5-year timeframe for members without a craniofacial anomaly and the 2-year timeframe for members with a craniofacial anomaly

Denial Risk

Replacement Criteria Not Met

Replacement criteria are not met unless the existing device is nonfunctional and cannot be repaired, or a documented change in the member’s condition makes it inadequate for hearing-related activities of daily living with expected improvement from replacement. A properly functioning device requested only for convenience or an early upgrade does not qualify.

Document nonfunctionality and irreparability, or the changed condition and hearing-related inadequacy
Document expected improvement with the replacement unit when replacement is based on changed condition
For processor replacement based on age, document at least 5 years without a craniofacial anomaly or at least 2 years with a craniofacial anomaly

May combine conductive and sensorineural hearing loss

Single-sided hearing loss/deafness

LateralityHearing loss affecting one ear

Included conditionSingle-sided sensorineural deafness

Policy applicationAddressed as a qualifying hearing-loss type under the policy