CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Hearing Aid Mandate (External Hearing Aids) Coverage Criteria

Policy governing coverage of external hearing aids under the Rhode Island hearing aid mandate for Blue Cross & Blue Shield of Rhode Island members, including device dollar maximums by age and applicable coding guidance.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHearing Aid Mandate (External Hearing Aids) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 14, 2014

Next Review DateN/A

Key ActionDo not submit prior authorization; prior authorization review is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$1,500max benefit (<19)

$700max benefit (19+)

every 3 yearsreplacement frequency

not requiredprior auth

Coverage Criteria

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Mandate coverage conditions

Age-based benefit: Under age 19: coverage up to $1,500 per individual hearing aid, per ear, per occurrence; Age 19 and older: coverage up to $700 per individual hearing aid, per ear, per occurrence.
Benefit replacement frequency: every three (3) years.

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The policy follows the Rhode Island hearing aid mandate definition: a hearing aid is "any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing," excluding batteries, cords, and other assistive listening devices. Batteries, cords, and assistive listening devices (examples include telephone amplifiers, alerting devices, television amplifiers, FM/DM systems and related accessories) are explicitly outside the hearing aid benefit and are not considered part of the mandated hearing aid coverage.

Certain related items (for example, ear molds/ear impressions) may be handled under DME or other benefit lines rather than under the hearing aid mandate; the policy lists specific HCPCS codes for batteries and assistive listening devices that are not included in the hearing aid definition and therefore are not covered as part of the mandate.

Services that are determined to be not medically necessary or otherwise non‑covered are not payable under this policy and may be denied. Providers may not bill the member for services denied as not medically necessary unless the provider has obtained the member's prior written agreement to accept financial responsibility.

This policy is informational and does not guarantee payment; providers should confirm member‑specific benefits and any applicable prior agreement or participation terms before billing members for non‑covered or not medically necessary services.

Coding and Financial Limits

Covered HCPCS/Codes and related device codesHCPCSCovered

V5030	Hearing aid, monaural, body worn, air conduction.
V5040	Hearing aid, monaural, body worn, bone conduction.
V5060	Hearing aid, monaural, in the ear.
V5070	Hearing aid, monaural, behind the ear.
V5120	Hearing aid, bilateral, body worn.
V5130	Hearing aid, binaural, body.
V5140	Hearing aid, binaural, behind the ear.
V5150	Hearing aid, binaural, glasses.
V5170	Hearing aid, CROS, in the ear.
V5171	Hearing aid, contralateral routing device, monaural, in the ear (effective 1/1/2019).

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Non-covered CPT/HCPCS codes for Commercial productsmixedNot Covered

92590	Hearing aid examination and selection; monaural.
92591	Hearing aid check; monaural.
92592	Hearing aid examination and selection; binaural.
92593	Hearing aid check; binaural.
92594	Electroacoustic evaluation for hearing aid; monaural.
92595	Electroacoustic evaluation for hearing aid; binaural.
V5010	Hearing aid examination and selection; monaural (listed as non-covered).
V5011	Hearing aid check; monaural (listed as non-covered).
V5014	Hearing aid examination and selection; binaural (listed as non-covered).
V5020	Hearing aid check; binaural (listed as non-covered).

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Age-based benefit maximum

Benefit maximum — under age 19$1,500 per individual hearing aid, per ear, per occurrence

Benefit maximum — age 19 and older$700 per individual hearing aid, per ear, per occurrence

Replacement frequencyEvery 3 years per mandate

Provider Actions, Prior Auth & Documentation

Prior Authorization

Prior authorization review is not required.

Note

Utilization Review

Carrier may conduct managed care, medical necessity, or utilization review as allowed by state law and contract terms. Providers should be prepared to submit clinical documentation supporting medical necessity when requested.

State mandate allows carrier-managed care and utilization review
Qualified Health Plans must cover Essential Health Benefits; consult subscriber agreement for member-specific coverage

Documentation Required

Coding & Documentation Notes

Use LT or RT modifiers on monaural codes to indicate the ear; do not use LT/RT on bilateral/binaural codes. Unlisted hearing aid and miscellaneous hearing service codes require submission of documentation for review per the unlisted code process. S0618 (audiometry for hearing aid evaluation) is not separately reimbursed.

LT/RT modifiers required on monaural codes
Unlisted codes: V5090, V5298, V5299 — documentation required for review
Not separately reimbursed: S0618

Denial Risk

Non-covered / Billing to Member

If services are determined not medically necessary or are non-covered benefits, providers may not bill the member unless the member was informed and provided written agreement in advance to pay at their own expense. Refer to the participation agreement and member benefit booklet for billing rules.

Provider billing to member requires prior written agreement when service is non-covered or not medically necessary
Contact provider call center for member-specific benefit questions

Background

Rhode Island state law requires coverage for external hearing aids for policies delivered, issued, or renewed in the state on or after January 1, 2006. The mandate establishes specified dollar maximums and a replacement frequency: members under age 19 are eligible for coverage up to $1,500 per hearing aid per ear, and members age 19 and older are eligible for coverage up to $700 per hearing aid per ear, with replacements permitted every 3 years in accordance with the mandate.

This policy applies only to external, nonexperimental, wearable hearing instruments that meet the mandate criteria and does not extend the mandate to items excluded by the statute (for example, batteries, cords, and other assistive listening devices).

Definitions

Hearing aid — definition

Definition (mandate)Any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing

ExclusionsExcludes batteries, cords, and other assistive listening devices (including FM systems)

ScopePolicy applies to external hearing aids (not to Hearing Aid Rider or non‑external devices)