CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Audiology diagnostic tests (coverage criteria)

This policy describes coverage and medical necessity for audiology diagnostic tests (standard and specialized) provided by licensed audiologists for BlueCHiP for Medicare and Commercial products in Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAudiology diagnostic tests (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionOrder audiology studies through a physician or mid-level practitioner and verify member benefits and eligibility before performing tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~30codes listed

Standard & specializedtest groups

Severalnot covered tests

Coverage and Medical Necessity Criteria

Medically Necessary Indications

Evaluation and diagnostic audiology tests are considered medically necessary when used to evaluate hearing impairment or related conditions.

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Indications: 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 the central auditory pathways.

From policy statement listing examples of covered clinical indications.

Covered Tests and Clinical Use

Standard and specialized tests are covered when appropriate to the patient's age and clinical situation.

Standard tests by age group: Adults/Children: pure-tone audiometry (air and bone conduction), speech audiometry, word recognition (word recognition/word discrimination) tests, tympanometry (impedance testing), acoustic reflex testing and acoustic reflex decay. Children-only: conditioned play audiometry, picture audiometry. Infants-only: visual reinforcement audiometry (VRA), auditory evoked potential / auditory brainstem response (ABR), evoked otoacoustic emissions (OAE), acoustic reflex tests.

Lists standard batteries by age group from policy background and test lists.

Specialized tests for adults and children (may be considered medically necessary when initial diagnostic tests are inconclusive or not appropriate): electrocochleography (ECochG), auditory evoked potentials, tone decay testing, sensorineural acuity level (SAL) test, Stenger test (pure tone or speech), evoked otoacoustic emissions (as specialized applications).

Specialized tests not part of initial work-up except when clinically indicated.

The policy identifies a set of audiometric procedures that are considered obsolete or not medically necessary and therefore are not covered for BlueCHiP for Medicare and are not medically necessary for Commercial products. Specifically, the document lists the alternate binaural loudness balance test, the Lombard test (noting it has been superseded by the Stenger test and auditory evoked potential), the short increment sensitivity test (SISI), and Bekesy audiometry as obsolete and not covered. In addition, the policy identifies tests for which there is insufficient evidence of efficacy and are not covered: the synthetic sentence identification test and the staggered spondaic word test.

The policy specifically names several tests that are considered not medically necessary or obsolete: Bekesy audiometry (both screening and diagnostic forms), the alternate binaural loudness balance (Lombard/loudness balance) test, the short increment sensitivity index (SISI), the synthetic sentence identification (SSI) test, and the staggered spondaic word (SSW) test. These tests are listed either as obsolete (replaced by more current methods such as pure-tone audiometry, Stenger testing, or auditory evoked potentials) or as lacking scientific literature to support clinical efficacy and therefore are not covered.

CPT / HCPCS Codes and Coding Details

Covered CPT/HCPCS Codes (listed as covered)CPTCovered

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
92563	Tone decay test
92565	Stenger test, pure tone
92567	Tympanometry (impedance testing)

1–10 of 23

1/3

Not covered / Not medically necessary codesCPTNot Covered

92559	Audiometry of groups testing
92560	Bekesy audiometry; screening
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

inv-07: Minimum frequencies for DPOAE comprehensive (92588)

Minimum frequencies requiredMinimum of 12 frequencies for comprehensive distortion product otoacoustic emissions (CPT 92588)

Applicable codeCPT 92588 — Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation

Context of useUsed as a comprehensive DPOAE diagnostic evaluation when otoacoustic emissions are indicated in the diagnostic work-up

Provider Requirements and Billing Guidance

Prior Authorization

Prior authorization is not required for audiology services.

Note

Provider Action

Order audiology tests only when requested by a physician or an authorized mid-level practitioner. Verify member benefits and eligibility prior to performing services to confirm coverage and any applicable limitations.

Billing Rule

Ordering and Benefit Verification

Audiology diagnostic tests performed by independently licensed audiologists are covered when ordered by a physician or mid-level practitioner for BlueCHiP for Medicare and Commercial products. Always verify benefits prior to the service.

Denial Risk

Not Covered / Potential Denial Codes

The following audiology procedures/tests may be subject to denial if billed inappropriately or when not medically necessary: Bekesy audiometry (screening 92561; diagnostic 92562), loudness balance test (92564), short increment sensitivity index (SISI) 92572, staggered spondaic word test 92576, and synthetic sentence identification test. Verify that services are ordered by a physician or mid-level provider and meet medical necessity criteria before billing.

CPT 92561 — Bekesy audiometry, screening
CPT 92562 — Bekesy audiometry, diagnostic
CPT 92564 — Loudness balance test
CPT 92572 — Short increment sensitivity index (SISI)
CPT 92576 — Staggered spondaic word test
Synthetic sentence identification test (CPT as applicable)

Background and Clinical Context

Hearing impairment ranges from slight reduction in sound perception up to complete deafness and may result from disorders of the ear, auditory nerve, or central auditory pathways. Loss may be sensorineural (cochlear or neural origin) or conductive (mechanical transmission loss in the outer or middle ear). Audiologists are the licensed specialists who identify, evaluate, and help rehabilitate persons with hearing loss; they perform diagnostic audiometric tests (standard batteries for adults, children, and infants, and specialized tests when clinically indicated) to characterize the type and degree of impairment and guide further management.

Definitions

inv-13: Definition of Audiology

Specialty definitionAudiology: the specialty focusing on identification, evaluation, and rehabilitation of persons with hearing impairment or loss

Typical providersServices are normally provided by a licensed audiologist who performs audiometric/diagnostic tests

Scope of testingEvaluates both sensorineural and conductive hearing losses using standard and specialized audiometric batteries

Age-specific practiceStandard batteries vary by age (adults, children, infants); specialized tests are used when initial diagnostics are inconclusive or not appropriate

Ordering/coverage noteAudiology diagnostic services are covered for BlueCHiP for Medicare and Commercial products when performed by licensed audiologists (see coding list) — verify benefits per member booklet