CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Audiology diagnostic testing (audiologic diagnostic tests) coverage criteria

Defines coverage and coding for audiologic diagnostic tests (pure-tone audiometry, speech audiometry, tympanometry, ABR, OAE, specialized tests) for BlueCHiP for Medicare and Commercial products; applies to providers performing audiology testing for plan members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAudiology diagnostic testing (audiologic diagnostic tests) coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits and document medical necessity per the member's Evidence of Coverage; check contract-specific prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+procedure and hearing test codes enumerated

Adult/Child/Infantstandard & specialized tests identified

5 namedobsolete / not medically necessary tests

Coverage Criteria — Audiology Diagnostic Testing

Medically necessary clinical indications

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Covered indications: Hearing loss; Otitis media; Meniere's disease; Labyrinthitis; Vertigo (dizziness); Tinnitus; Cochlear otosclerosis; Neoplasms of the auditory or central nervous system; Congenital anomalies; Surgery involving the auditory and/or central nervous system (e.g., skull-based tumors such as acoustic neuroma and meningioma); Facial nerve paralysis (Bell's palsy); Bacterial meningitis; Exposure to intense noise; Ototoxic drugs; Fractures of the temporal bone or trauma affecting the central auditory pathways.

From policy statement

Age-specific standard test coverage

Standard and age-specific test batteries are covered when used as part of the initial diagnostic work-up:

Adults and children standard battery: Pure-tone audiometry (air and bone conduction), speech audiometry, word recognition tests, tympanometry (impedance testing), acoustic reflex testing and acoustic reflex decay.

Listed under For Adults and Children

Children-specific tests: Conditioning play audiometry and select picture audiometry for children as appropriate.

Listed under For Children Only

Infant-specific tests: Visual reinforcement audiometry (VRA), Auditory Brainstem Response (ABR)/Auditory evoked potential, evoked otoacoustic emissions (OAE), and acoustic reflex testing for infants as appropriate.

Listed under For Infants Only

Specialized testing criteria

Specialized tests are covered when initial diagnostic tests are inconclusive or not appropriate to the clinical situation:

Specialized tests when initial tests inconclusive: Auditory evoked potentials (including ABR), tone decay test, Stenger test (pure tone or speech), Sensorineural Acuity Level (SAL) test, evoked otoacoustic emissions, electrocochleography; these tests are considered medically necessary in specific clinical situations when initial diagnostics are inconclusive or inappropriate.

From Background and Specialized Tests

The policy references several specific tests by name as part of the coverage considerations. These include alternate binaural loudness balance (CPT 92562), the Lombard test (historically used but largely replaced by the Stenger test and auditory evoked potentials), the Short Increment Sensitivity Index (SISI) (CPT 92564), Bekesy audiometry (CPT 92561), and the Synthetic Sentence Identification (SSI) test (CPT 92576).

Specialized tests that are described as appropriate when initial diagnostics are inconclusive or not suitable include Auditory Evoked Potentials (ABR), tone decay testing, the Stenger test (pure tone or speech), the Sensorineural Acuity Level (SAL) test, and evoked otoacoustic emissions.

The policy explicitly identifies a set of audiometric procedures that are considered obsolete or not medically necessary. Tests named as obsolete include the alternate binaural loudness balance test, the Lombard test, the Short Increment Sensitivity Index (SISI), and Bekesy audiometry (CPT 92561).

Additionally, tests identified as having insufficient scientific support and therefore not medically necessary include the Synthetic Sentence Identification (SSI) test (CPT 92576) and the Staggered Spondaic Word (SSW) test (CPT 92572). These exclusions are applied consistent with the policy’s statement that those specific tests are obsolete or lack evidence of efficacy.

Coding — CPT / HCPCS

Covered CPT/HCPCS CodesmixedCovered

92551	Screening test, pure tone, air only
92552	Pure tone audiometry (threshold); air only
V5008	Hearing screening
92550	Tympanometry and reflex threshold measurements
92553	Pure tone audiometry (threshold); air and bone
92555	Speech audiometry threshold
92556	Speech audiometry threshold; with speech recognition
92557	Comprehensive audiometry threshold evaluation and speech recognition
92563	Tone decay test
92565	Stenger test, pure tone

1–10 of 24

1/3

Not medically necessary / Obsolete testsCPTNot Covered

92561	Bekesy audiometry; diagnostic
92562	Loudness balance test; alternate binaural or monaural
92564	Short increment sensitivity index (SISI)
92572	Staggered spondaic word test
92576	Synthetic sentence identification test

Codes noted as not medically necessary for all productsCPTNot Covered

92559	Audiometric group testing
92560	Audiometry; screening

Provider Actions and Billing Guidance

Documentation Required

Benefit verification and documentation

Benefits and eligibility may vary by group/contract. Verify member-specific benefits by checking the member's Evidence of Coverage/subscriber agreement or calling the BCBSRI provider call center prior to providing services.

Verify member benefits and document medical necessity per the Evidence of Coverage/subscriber agreement.
If services are determined to be not medically necessary or are non-covered benefits, do not bill the member unless the member was informed and agreed in advance to accept financial responsibility.

Prior Authorization

Order and prior authorization requirements

Audiology studies performed by independently licensed audiologists are covered diagnostic services only when ordered by a physician or a mid-level practitioner. Ensure an appropriate order is on file; lack of a valid order may result in denial or payment recoupment.

Tests must be ordered by a physician or mid-level practitioner.
Services performed without an appropriate order may be denied.
Check contract-specific prior authorization requirements — benefits and prior auth rules may vary by group/contract.

Background

Audiology services consist of diagnostic and rehabilitative audiometric evaluations performed by licensed audiologists to identify and quantify hearing impairment. The purpose of testing is to determine the type (sensorineural versus conductive), degree, and functional impact of hearing loss and to guide appropriate management including medical or surgical referral, hearing conservation, or amplification.

Standard test batteries vary by age and clinical context: for adults and children this typically includes pure-tone audiometry (air and bone), speech audiometry/word recognition, tympanometry, and acoustic reflex testing. Pediatric-specific procedures include conditioning play audiometry and select picture audiometry; infant assessments use visual reinforcement audiometry (VRA), Auditory Brainstem Response (ABR), and otoacoustic emissions (OAE) as appropriate.

When initial diagnostic testing is inconclusive or not appropriate, specialized procedures such as auditory evoked potentials, tone decay, Stenger testing, sensorineural acuity level (SAL) testing, electrocochleography, and evoked otoacoustic emissions are used to further characterize auditory function and confirm diagnoses.

Definitions

Audiological services — definition

DefinitionAudiological services are diagnostic and rehabilitative tests performed by a licensed audiologist to evaluate sensorineural and conductive hearing impairments.

ProviderPerformed by a licensed audiologist.

PurposeIdentification, evaluation and rehabilitation of persons with hearing impairment or hearing loss.

Test typesIncludes audiometric/diagnostic tests that evaluate both sensorineural and conductive hearing losses (standard and specialized batteries).

Specialized tests — definition and use

When usedSpecialized tests are used in specific clinical situations or when initial diagnostic tests are inconclusive or not appropriate.

Named specialized testsAuditory Evoked Potentials (including ABR), tone decay test, Stenger test (pure tone or speech), Sensorineural Acuity Level (SAL) test, and evoked otoacoustic emissions (OAE).

Infant-specific specialized testsAuditory evoked potential (Auditory Brainstem Response, ABR) and evoked otoacoustic emissions (OAE) listed for infants as appropriate.

Role relative to standard batteriesNot part of the initial work-up but may be medically necessary when standard/initial tests are inconclusive or inappropriate.