CurrentArizona Complete HealthPolicy CP.MP.93

Bone-Anchored Hearing Aid (BAHA) Coverage Criteria

Defines medical necessity, replacement, and coding guidance for bone-anchored hearing aids and external components for members/enrollees of the Health Plan.

Policy Summary

PayerArizona Complete Health

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 document clinical indications and required audiometric thresholds when requesting implantation or external device coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

age ≥ 5minimum age for implantable device

≥ 60%unaided speech discrimination

< 20 dBhearing ear BC threshold

≥ 5 yrsprocessor age for replacement

CPT/HCPCScodes referenced

Coverage Criteria

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Initial BAHA

Covered when ALL of the following are met:

Initial BAHA medical necessity: A. Implantable device for age ≥ five years; or head band device for age < five years or medically unable to have an implant;

Document patient age and device type requested (implantable vs headband).

Initial BAHA medical necessity: 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;

Indication type must be documented (e.g., canal malformation, chronic infection, allergy, unilateral deafness due to tumor/removal/trauma/viral/vascular/idiopathic).

Initial BAHA medical necessity: C. Pure tone average bone conduction threshold (measured at 0.5, 1, 2, and 3 kHz) is consistent with the FDA indications for the requested device AND unaided speech discrimination score ≥ 60%;Pure tone average per FDA for device; unaided speech discrimination ≥ 60%

Exact FDA-concordant bone conduction thresholds required per device; document thresholds and unaided speech discrimination score.

Initial BAHA medical necessity: D. For bilateral BAHA, there is a mean maximum difference < 10 dB between right and left bone conduction thresholds;mean maximum difference < 10 dB

Document interaural bone conduction difference for bilateral devices.

Initial BAHA medical necessity: E. For unilateral deafness, the hearing ear should have a bone conduction threshold of < 20 dB;hearing ear bone conduction threshold < 20 dB

Document hearing ear bone conduction threshold for unilateral deafness.

Initial BAHA medical necessity: F. One of the following specific indications is present: 1) congenital or surgically induced malformation of the ear canal such that it does not exist or cannot accommodate a standard air-conduction hearing aid (provided the nerve is functional); 2) chronic infection or dermatitis of the middle or outer ear that is exacerbated by a standard air-conduction hearing aid; 3) allergic reactions to standard air-conduction hearing aids; 4) unilateral deafness that occurred after removal of an acoustic neuroma, from trauma, from a viral or vascular insult, or from 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, and feedback effects).

Document the specific clinical indication supporting BAHA selection.

Replacement / Upgrade

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

Replacement/upgrade medical necessity: A. The existing device(s) is no longer functional and cannot be repaired;

Document device functionality and repair attempts.

Replacement/upgrade medical necessity: 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 unit(s);

Document clinical change and expected functional improvement with replacement.

Replacement/upgrade medical necessity: C. The current sound processor is at least five years old.current processor ≥ 5 years

Document age of current sound processor.

Not Medically Necessary (upgrades for convenience)

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

Requests not meeting criteria in section II risk denial; document rationale for upgrade and age/function of current device.

The policy previously included a blanket exclusion stating that BAHAs for any other indication are considered not medically necessary; that blanket statement has been removed. Current policy instead specifies a defined set of covered clinical indications and the medical necessity criteria that must be met for coverage decisions.

Replacement or upgrade of an existing, properly functioning bone-anchored hearing aid (BAHA) and/or its external components is not medically necessary when requested solely for convenience or to obtain newer technology before the timeframe noted in section II. The policy defines medically necessary replacement/upgrade as when any of the following are met: the existing device is no longer functional and cannot be repaired; a change in condition makes the existing unit inadequate for hearing-related activities of daily living with expected improvement from replacement; or the current sound processor is at least five years old.

Coding and 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: Pure tone average bone conduction threshold — measured at 0.5, 1, 2, 3 kHz (consistent with FDA indications)

Measurement frequenciesMeasured at 0.5, 1, 2, and 3 kHz (pure tone average bone conduction)

Concordance requirementMust be consistent with FDA indications for the requested device

Use in decision-makingApplied to determine candidacy for implantable vs external/headband devices

inv-09: Unaided speech discrimination score — threshold value

Threshold valueUnaided speech discrimination score ≥ 60%

RolePart of combined criteria with pure tone average to establish medical necessity

DocumentationRecord unaided speech discrimination score in authorization/medical record

inv-10: Interaural bone conduction difference for bilateral BAHA — mean maximum difference threshold

ThresholdMean maximum difference < 10 dB between right and left bone conduction thresholds

Applies toBilateral BAHA candidacy

MeasurementCalculated from bone conduction thresholds used in pure tone average

inv-11: Hearing ear bone conduction threshold for unilateral deafness — threshold value

Threshold valueHearing ear bone conduction threshold < 20 dB

Applies toUnilateral deafness indication

PurposeEnsures contralateral (hearing) ear has near-normal bone conduction for benefit from BAHA

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for bone-anchored hearing aids (BAHAs) and related surgical procedures and external components. Requests that do not meet the clinical indications and documentation requirements below are subject to denial.

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

Denial Risk

Coverage Contingent on Clinical Indications

Coverage is contingent on meeting the clinical indications listed in the policy. Requests that do not meet ALL required indications or lack required supporting documentation risk denial.

Documentation Required

Required Clinical Documentation

Submit complete clinical documentation with the prior authorization request. At a minimum include: member age; device type requested (implantable vs headband/external); pure tone average bone conduction thresholds (0.5, 1, 2, 3 kHz) and mean difference for bilateral requests; unaided speech discrimination score; indication(s) from policy (e.g., congenital ear canal malformation, chronic infection, allergic reaction, unilateral deafness, large conductive loss); history of prior air-conduction hearing aid use and reason for failure; date and description of prior BAHA sound processor and age of current processor if replacement (noting if ≥5 years); and operative reports or consult notes as applicable.

Note

Provider Action / Warning

Providers must verify that all medical necessity criteria are met prior to submission: age criteria (implantable device ≥5 years; headband <5 years or if medically unable to have implant), hearing loss type (conductive/mixed or unilateral sensorineural where conventional aids cannot restore hearing), pure tone and speech discrimination thresholds per FDA/device indications, and specific situational indications listed in policy (see list).

OpenPayer

Bone-Anchored Hearing Aid (BAHA) Coverage Criteria

Coverage Criteria

Coding and Clinical Thresholds

Provider Actions & Requirements

Background

Definitions