Medical record review / prior authorization

Prior authorization or a medical necessity determination may be required for implantable bone-conduction hearing aids. BCBSNC may request medical records to determine medical necessity; when records are requested, letters of support/explanation are useful but are not sufficient unless they include all specific information needed for the medical necessity determination.

• Obtain prior authorization per insurer procedures before implantation when applicable.
• Be prepared to submit complete medical records if requested to support medical necessity.

Prior authorization / billing codes

The policy's Billing/Coding section lists multiple CPT and HCPCS codes relevant to implantable bone-conduction devices and has been revised repeatedly; prior authorization and billing should follow current insurer practices and the specific codes listed in the policy.

• Verify and use the current CPT/HCPCS codes listed in the policy (e.g., 69710–69730 series, 92622–92623, L8625, L8690–L8694) when submitting claims.
• Note that codes have been added and removed over time; confirm the active codes at time of billing.

Benefits verification

Review the member's benefit design in the Member's Benefit Booklet to determine availability of benefits prior to applying this medical policy, since member benefits may vary according to benefit design.

• Confirm coverage availability and any age‑specific or frequency limits before scheduling procedures.

Policy position: implantable bone-conduction devices

Implantable bone-conduction devices are positioned as alternatives to air-conduction hearing aids or CROS devices when the patient's age, medical indications, and device-specific audiologic thresholds meet the policy's When Covered criteria.

• Ensure patient meets the When Covered criteria (age thresholds and device-specific pure tone average bone‑conduction limits) before pursuing implantation.

Records upon request — completeness required

BCBSNC may request medical records to determine medical necessity; letters without full specific information are not sufficient documentation unless they include all specific information needed to make the determination.

• Provide complete audiologic and clinical records when responding to a records request; do not rely on unsupported letters of recommendation alone.

Documentation of age and audiologic thresholds

When Covered criteria specify patient age and device‑specific audiologic thresholds (pure tone average bone‑conduction thresholds at 0.5, 1, 2, and 3 kHz and, for single‑sided deafness, AC PTA of the normal ear), those measurements must be documented in the medical record to establish coverage eligibility.

• Document age (e.g., ≥5 years; device-specific older age limits for some systems historically) and device‑specific PTA bone‑conduction thresholds (e.g., ≤45 dB, ≤55 dB, or ≤65 dB depending on device) in the chart.
• For single-sided sensorineural deafness, document the normal ear's AC PTA better than 20 dB at 0.5, 1, 2, and 3 kHz.

Investigational indications and denial risk

Use of implantable bone-conduction devices for indications not listed in the When Covered section — including use in individuals with bilateral sensorineural hearing loss or non‑implantable intraoral devices — is considered investigational and may be denied.

• Do not submit claims or prior authorization requests for bilateral sensorineural hearing loss or intraoral non‑implantable devices under this policy; these indications are investigational.

Coverage restriction — unsupported indications

An implantable bone conduction hearing aid is not covered for indications other than those listed in the When Covered section; use for bilateral sensorineural hearing loss is specifically considered investigational and not covered.

• Confirm the patient's indication matches the When Covered criteria before requesting authorization or submitting claims to avoid denials.