Modifiedblue cross blue shield - michiganPolicy N/A

Hearing Services (BCN Advantage Medicare Advantage Enhanced Benefit)

Defines BCN Advantage (Medicare Advantage HMO) enhanced hearing services benefit, including covered evaluations, hearing aid coverage, provider/payment conditions, billing and member cost sharing for plan members.

Policy Summary

Payerblue cross blue shield - michigan

PolicyHearing Services (BCN Advantage Medicare Advantage Enhanced Benefit)

Policy CodePolicy N/A

Change TypeCodes added to payment conditionstemplate transition

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify benefits, reimbursement methodology and member cost sharing via the BCN provider portal or BCN Advantage before billing or dispensing hearing aids.

SourceLink

POLICY UPDATE CHANGES

Transitioned to new template and changes made to payment conditions to include additional codes.

Added the following codes to payment conditions: V5090, V5110, V5160, V5200, V5240, V5241, V5262, V5263, V5298, 92558, 92590, 92591, 92592, 92593, 92594, 92595.

36 monthsfrequency limit per ear

16payment-condition codes added

S0618, V50xx,92590-95key codes listed

01/01/2026effective date

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Coverage Criteria

Standard Hearing Aid Coverage

Standard hearing aids and associated evaluation services are covered when ALL of the following are met:

Prescribing/fitting and evaluation: Hearing aids must be prescribed by a physician, audiologist, or hearing aid dealer based on the most recent audiometric examination and hearing aid evaluation test.

Medical evaluation required: A medical evaluation is required to determine the cause of the hearing loss and whether it can be improved with a hearing aid; this evaluation is covered under the base Medicare office visit benefit.

Provider and frequency conditions: Hearing aids are subject to a 36-month frequency limitation per ear and must be furnished by a physician, audiologist, or other qualified provider; services must be obtained from a participating in‑network provider.36 months per ear

Significant change in hearing loss requires documentation to justify earlier replacement.

Coverage includes applicable dispensing fees but excludes additional hearing aid batteries, repairs, adjustments, or reconfigurations; member is responsible for the difference between the plan's benefit and the cost of the hearing aid(s).

Prosthetic Device Coverage (Medicare guidance)

Medicare-payable prosthetic devices (when hearing aids are medically inappropriate):

Prosthetic devices: Cochlear implants, auditory brainstem implants, and osseointegrated implants may be payable by Medicare when hearing aids are medically inappropriate or cannot be utilized due to congenital malformation, chronic disease, severe sensorineural hearing loss, or surgery.

The following services and items are excluded from the BCN Advantage enhanced hearing services benefit and are the member's financial responsibility when provided: testing of different devices; drugs; medical treatment and evaluation that is appropriately covered under Medicare Parts A or B; replacement parts or spare hearing aids; examinations related to medical surgical procedures or hearing aid fittings; hearing aids that do not carry FDA approval; unnecessary services not prescribed by the physician specialist, audiologist, or hearing aid dealer; and hearing aids ordered while the member has BCN Advantage coverage but delivered more than 60 days after coverage ends.

CMS coverage policies are updated periodically and may change after this policy's review date. The most current CMS guidance may not be reflected here; providers should consult CMS.gov for up-to-date Medicare coverage information.

Enhanced features on a digital hearing aid and other unnecessary services are explicitly excluded as noncovered. Coverage does not extend to add-on or enhanced digital features beyond standard hearing aid functionality; such features are considered noncovered and may result in member financial responsibility if provided without prior authorization or coverage determination.

Coding and Frequency Limits

Applicable HCPCS/CPT group 1HCPCSCovered

S0618	Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
V5010	Assessment for hearing aid
V5020	Conformity evaluation
V5030	Hearing aid, monaural, body worn, air conduction
V5040	Hearing aid, monaural, body worn, bone conduction
V5050	Hearing aid, monaural, in the ear
V5060	Hearing aid, monaural, behind the ear
V5070	Glasses, air conduction
V5080	Glasses, bone conduction
V5090	Dispensing fee, unspecified hearing aid

1–10 of 16

1/2

Applicable HCPCS/CPT group 2mixedCovered

V5160	Dispensing fee, binaural
V5171	Hearing aid, contralateral routing device, monaural, in the ear (ITE)
V5172	Hearing aid, contralateral routing device, monaural, in the canal (ITC)
V5181	Hearing aid, contralateral routing device, monaural, behind the ear (BTE)
V5190	Hearing aid, contralateral routing, monaural, glasses
V5200	Dispensing fee, contralateral, monaural
V5211	Hearing aid, contralateral routing system, binaural, ITE/ITE
V5212	Hearing aid, contralateral routing system, binaural, ITE/ITC
V5213	Hearing aid, contralateral routing system, binaural, ITE/BTE
V5214	Hearing aid, contralateral routing system, binaural, ITC/ITC

1–10 of 46

1/5

ICD-10 CodesICD-10

ICD-10 codes: Not specified; placeholder in document

Codes added to payment conditionsmixed

V5090
V5110
V5160
V5200
V5240
V5241
V5262
V5263
V5298
92558

1–10 of 16

1/2

Frequency limit

Frequency limitOnce every 36 months per ear; earlier replacement permitted only with documentation of a significant change in hearing loss

Documentation requiredMedical documentation of the significant change in hearing loss must be submitted to justify replacement before 36 months

Applies toStandard hearing aids and associated dispensing services (per ear)

Provider furnishing requirementMust be furnished by eligible providers (MD/DO, audiologist, or hearing aid dealer) as listed in payment conditions

Provider Actions and Billing

Prior Authorization

Verify benefit and payment details

Since Original Medicare limits coverage of hearing services, BCN Advantage groups determine coverage scope, reimbursement methodology, maximum payment amounts and member cost sharing for this enhanced benefit. Verify member benefits and applicable BCN Advantage payment rules prior to providing services — coverage and payment vary by group.

Benefit scope and payment methodology vary by BCN Advantage group
Verify BCN Advantage fee schedule in Availity Essentials™ (Secure Provider Resources → BCN Fee Schedules) to determine maximum payment amounts

Prior Authorization

Check payer policies for prior authorization

Providers must review BCBSM/BCN reimbursement policies and the BCN provider manual for prior authorization or other pre-claim requirements before submitting claims. Failure to obtain prior authorization when required may result in claim denials.

Check BCBSM/BCN reimbursement policies for any prior authorization requirements
Review the BCN provider manual for claim submission rules

Background

Hearing loss falls into three general types that determine evaluation and treatment options: conductive loss (problems of the outer or middle ear that may be medically or surgically reversible), sensorineural loss (inner ear damage that is often permanent and typically managed with hearing aids), and mixed loss (a combination of conductive and sensorineural components). A medical evaluation based on the most recent audiometric examination is required to determine the cause of hearing loss and whether a hearing aid or a Medicare-payable prosthetic device is appropriate.

Definitions

Conductive hearing loss

DefinitionConductive hearing loss affects the outer or middle ear and creates a barrier to sound transmission to the inner ear

Typical courseMost conductive losses are not permanent and may be treatable with medication or surgery

Common causes (examples)Wax occlusion, otitis media (middle ear infection), perforated eardrum, otosclerosis

Sensorineural hearing loss

DefinitionSensorineural hearing loss is caused by damage to the inner ear hair cells, resulting in impaired transmission of auditory signals to the brain

Typical courseSensorineural hearing loss is permanent and typically addressed with fitting of hearing aids for sound stimulation

Policy Summary

Payerblue cross blue shield - michigan

PolicyHearing Services (BCN Advantage Medicare Advantage Enhanced Benefit)

Policy CodePolicy N/A

Change TypeCodes added to payment conditionstemplate transition

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify benefits, reimbursement methodology and member cost sharing via the BCN provider portal or BCN Advantage before billing or dispensing hearing aids.

SourceLink

On This Page

Billing Rule

Frequency limitation

Standard hearing aids are subject to a frequency limitation of once every 36 months per ear. Replacements prior to the 36‑month limit require documentation of a significant change in hearing loss.

Frequency limit: 36 months per ear
Replacements before 36 months require documentation of significant change in hearing loss

Documentation Required

Required documentation and medical evaluation

A medical evaluation based on the most recent audiometric examination and a hearing aid evaluation are required prior to dispensing hearing aids. Coverage includes applicable dispensing fees but excludes batteries, routine repairs, adjustments, or reconfigurations. Providers must obtain and retain documentation of the exams and evaluations.

Medical evaluation and audiometric exam required prior to dispensing
Hearing aid fitting/evaluation tests and conformity tests are covered as part of the medical evaluation component
Dispensing fees covered; batteries, repairs, adjustments excluded (member financial responsibility)

Documentation Required

Supporting Documentation Requirement

Non‑contracted providers may be required to submit supporting documentation, including relevant medical records, to substantiate billed services. Providers contracted with BCN should follow the provider manual; non‑contracted providers should expect additional documentation requests.

Non‑contracted providers may need to submit medical records supporting billed claims
Contracted providers must follow BCN provider manual requirements

Denial Risk

Noncovered items/financial responsibility

The following services and items are not covered under the BCN Advantage enhanced hearing benefit; members are financially responsible for noncovered services. Providers may not have members sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility for noncovered items. If there is uncertainty about coverage, obtain a coverage determination from BCN Advantage before providing the service.

Testing of different devices — not covered
Drugs — not covered
Medical treatment/evaluation appropriately covered under Medicare Parts A or B — not covered under enhanced benefit
Replacement parts or spare hearing aids — not covered
Examinations related to medical surgical procedures or hearing aid fittings — not covered
Enhanced features on a digital hearing aid — not covered
Hearing aids lacking FDA approval — not covered
Unnecessary services not prescribed by an authorized prescriber — not covered
Hearing aids ordered during coverage but delivered >60 days after coverage ends — not covered
If member elects a noncovered service, member is responsible for the entire charge (except applicable BCN Advantage cost share)

Denial Risk

Documentation / Claim Submission Risk

Failure to review applicable BCBSM reimbursement policies or the BCN provider manual prior to claim submission may result in denied claims or requests for additional documentation. Verify member cost share and collect appropriate BCN Advantage cost sharing at time of service when possible.

Providers must review BCBSM/BCN policies before billing to avoid denials
Verify member cost sharing via Availity or by calling BCN (1-866-309-1719) and collect only the appropriate BCN Advantage cost share
If a noncovered item is provided without a prior coverage determination, the member must be held harmless except for applicable cost share

Common causes (examples)Noise damage, presbycusis (age-related loss), viral inner ear infections, ototoxic medications

Mixed hearing loss

DefinitionMixed hearing loss consists of both conductive and sensorineural components occurring together

Clinical implicationEvaluation should identify and address both reversible conductive elements and permanent sensorineural elements

ManagementTreatment may combine medical/surgical care for conductive causes and hearing aids for sensorineural loss

Medicare Advantage Enhanced Benefit Policy

DefinitionMedicare Advantage Enhanced Benefit Policy: criteria BCBSM and BCN use to determine reasonable and necessary services when Medicare coverage rules are not fully developed

GovernanceIndividual member plan documents (Evidence of Coverage, Annual Notice of Change) and applicable laws govern benefit coverage and restrictions

Provider responsibilitiesProviders must review applicable BCBSM reimbursement policies and provider manual prior to claim submission; non-contracted providers may need to submit supporting documentation