CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Diagnostic Audiology and Hearing Tests Coverage Criteria

This policy governs coverage and coding for diagnostic audiology and hearing tests provided to Medicare Advantage and commercial members of Blue Cross Blue Shield - Rhode Island, including which tests are considered medically necessary or not covered.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDiagnostic Audiology and Hearing Tests Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionOrder diagnostic audiology tests when clinically indicated and verify member benefits before testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40specific test codes referenced in the policy

Adult/Child/Infantage groups with specified standard tests

Some not coveredMedicare Advantage distinctions

Coverage and Medical Necessity Criteria

Medically Necessary Indications

Evaluation and diagnostic audiology tests are considered medically necessary for evaluation of hearing impairment when associated with specified clinical indications.

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Medically necessary indications: Evaluation and impairment tests are medically necessary in illnesses or injuries including, but not limited to: 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 central auditory pathways.

From policy statement listing clinical indications

Test Selection by Age / Specialized Testing

Standard and specialized tests by age group:

Adult/Child standard tests: Pure‑tone audiometry (air and bone conduction); word recognition/speech audiometry including speech recognition/word recognition tests; acoustic reflex testing including acoustic reflex decay; tympanometry (impedance testing).

Listed under 'For Adults and Children'

Children only tests: Conditioned play audiometry; select picture audiometry.

Listed under 'For Children Only'

Infant only tests: Visual reinforcement audiometry (VRA); auditory evoked potential (Auditory Brainstem Response, ABR); evoked otoacoustic emissions (OAE); acoustic reflex test.

Listed under 'For Infants Only'

Specialized tests: Auditory evoked potentials; tone decay tests; sensorineural acuity level (SAL) test; Stenger tests (pure tone or speech); evoked otoacoustic emissions. Specialized tests may be medically necessary when initial diagnostic tests are inconclusive or not appropriate to the condition.

From 'Specialized Tests' and background

Certain older audiometric procedures are explicitly identified in this policy as obsolete and are not covered for Medicare Advantage Plans and not medically necessary for Commercial products. This distinction applies to tests that have been superseded by more accurate or validated methods, or for which there is insufficient scientific evidence of clinical benefit. Providers should order current, guideline-supported audiologic testing appropriate to the patient’s age and clinical presentation.

The policy lists specific obsolete tests and tests lacking supporting literature that are not covered for Medicare Advantage Plans and not medically necessary for Commercial products. Obsolete tests include: alternate binaural loudness balance test, Lombard test (replaced by the Stenger test and auditory evoked potential), short increment sensitivity test (replaced by pure tone audiometry and auditory evoked potential), and Bekesy audiometry. Tests identified as having no supporting scientific literature include the synthetic sentence identification test and the staggered spondaic word test. Corresponding CPT codes explicitly listed as not covered/not medically necessary are 92562 (loudness balance test), 92572 (staggered spondaic word test), and 92576 (synthetic sentence identification test).

Billing Codes and Coverage Status

Covered CPT/HCPCS CodesmixedCovered

92550	Tympanometry and reflex threshold measurements
92551	Screening test, pure tone, air only
92552	Pure tone audiometry (threshold); air only
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 (92553 and 92556 combined)
92563	Tone decay test
92565	Stenger test, pure tone
92567	Tympanometry (impedance testing)

1–10 of 26

1/3

Not covered / Not medically necessary (Medicare Advantage and Commercial)CPTNot Covered

92562	Loudness balance test, alternate binaural or monaural
92572	Staggered spondaic word test
92576	Synthetic sentence identification test

Provider Responsibilities, Prior Authorization, and Billing Notes

Prior Authorization

Not applicable

Note

Provider Guidance

Provider action: preserve raw callout content for provider guidance.

Note

Ordering and Benefit Verification

Hearing exams and diagnostic hearing tests are covered when furnished by a physician, audiologist, or other qualified provider. Audiology studies performed by independently licensed audiologists are covered diagnostic services when ordered by a physician or an Advanced Practice Provider. Benefits may vary between groups/contracts; verify member benefits in the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement before providing services.

Order and verify benefits prior to testing
Covered when ordered by a physician or Advanced Practice Provider
Performed by physicians, audiologists, or other qualified providers

Denial Risk

Non-covered / Not Medically Necessary Codes

The following hearing test codes are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial products.

CPT 92562 — Loudness balance test, alternate binaural or monaural
CPT 92572 — Staggered spondaic word test
CPT 92576 — Synthetic sentence identification test

Clinical Background

Hearing impairment ranges from slight loss to complete deafness and may result from sensorineural causes (cochlear or neural pathology) or conductive causes (middle ear dysfunction). Audiology evaluates these conditions using standardized and specialized audiometric tests to identify the type and degree of impairment and to guide management.

Standard diagnostic testing differs by age group: for adults and children this typically includes pure‑tone audiometry (air and bone), speech audiometry/word recognition, and tympanometry/acoustic reflex testing; children may require conditioned play or picture audiometry; infants require methods such as visual reinforcement audiometry (VRA), auditory brainstem response (ABR), and otoacoustic emissions. Specialized tests (for adults and children) such as auditory evoked potentials, tone decay, sensorineural acuity level (SAL) and Stenger tests are used when initial diagnostics are inconclusive or not appropriate.

Audiological testing is performed by licensed audiologists and is intended to provide diagnostic information to clinicians for medical decision making, referral, and where appropriate, rehabilitation planning (for example, candidacy for hearing aids or cochlear implants).

Definitions

Audiological services definition — diagnostic and rehabilitative services provided by licensed audiologists

DefinitionAudiological services are diagnostic and rehabilitative services provided by licensed audiologists performing audiometric/diagnostic tests to evaluate sensorineural and conductive hearing impairment/losses.

ProvidersServices are normally provided by a licensed audiologist.

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

Test scopeIncludes standard audiometric batteries and specialized tests to evaluate sensorineural and conductive pathology.

When specialized tests usedSpecialized tests may be considered medically necessary when initial diagnostic tests are inconclusive or not appropriate to the condition.