CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Hearing Aids (external) — Rhode Island mandate coverage

Defines coverage limits and coding for external hearing aids under the Rhode Island hearing aid mandate for commercial products; affects commercial plan members and providers billing hearing aids and related HCPCS/CPT codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyHearing Aids (external) — Rhode Island mandate coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit prior authorization—prior authorization is not required for hearing aids under this policy for Commercial products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$1,500coverage per aid (<19 yrs)

$700coverage per aid (≥19 yrs)

every 3 yearsreplacement interval

Commercialapplicability

Coverage criteria

Mandated coverage conditions: (1) Device is an external, nonexperimental hearing aid as defined by the Rhode Island mandate (hearing aid excludes batteries, cords, and other assistive listening devices, including FM systems); (2) Member is covered under a Commercial product governed by this policy (coverage applies to commercial plans as specified by statute); (3) Coverage limits per individual aid do not exceed the statutory amounts: $1,500 per aid per occurrence for members under 19 years; $700 per aid per occurrence for members 19 years and older; (4) Replacement is per occurrence and typically not more than once every three years.$1,500 (under 19 years) / $700 (19 years and older)

See statute S 27-20-46 for definitions and age-based dollar limits.

This policy defines the scope of the Rhode Island hearing aid mandate as applying only to external, nonexperimental hearing aids and explicitly excludes batteries, cords, and other assistive listening devices (including FM systems). Codes for assistive listening devices and supplies (for example HCPCS V5266–V5274 and V5281–V5290 series) are not considered part of the hearing aid benefit under the mandate and are treated separately; such items may be covered only under the member’s DME or other benefits if applicable. The policy applies to Commercial products only and does not address coverage under any optional Hearing Aid Rider.

This medical policy is provided for informational purposes and is not a guarantee of payment. Member benefits and eligibility are determined by the member’s subscriber agreement, certificate, or employer agreement, which supersede this policy. Services determined to be not medically necessary or non-covered may not be paid; providers should follow member documents and their participation agreements and obtain appropriate authorization or member acknowledgement when required.

Coding and reimbursement

Covered HCPCS hearing aid codes (examples listed)HCPCSCovered

V5030	Hearing aid, monaural, body worn, air conduction
V5040	Hearing aid, monaural, body worn, bone conduction
V5050	Hearing aid, monaural, in the ear
V5060	Hearing aid, monaural, behind the ear
V5070	Hearing aid, bilateral, body worn
V5120	Binaural, body
V5130	Binaural, in the ear
V5140	Binaural, behind the ear
V5242	Hearing aid, analog, monaural, CIC
V5243	Hearing aid, analog, monaural, ITC

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Non-covered CPT/HCPCS codesmixedNot Covered

92590	Hearing aid examination and selection; monaural
92591	Hearing aid examination and selection; binaural
92592	Hearing aid check; monaural
92593	Hearing aid check; binaural
92594	Electroacoustic evaluation for aid; monaural
92595	Electroacoustic evaluation for aid; binaural
V5011	Fitting/orientation/checking of hearing aid
V5014	Repair/modification of a hearing aid
V5020	Conformity evaluation
V5110	Dispensing fee, bilateral

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Codes subject to unlisted code process or DME benefitHCPCS

V5264	Ear mold/insert, not disposable, any type
V5265	Ear mold/insert, disposable, any type
V5090	Dispensing fee, unspecified hearing aid (unlisted code process)
V5298	Hearing aid, not otherwise classified (unlisted)
V5299	Service, miscellaneous Hearing (unlisted)

Assistive listening devices and supplies (non-covered under mandate)HCPCSNot Covered

V5266	Battery for use in hearing device
V5267	Hearing aid or assistive listening device supplies/accessories NOS
V5268	Assistive listening device, telephone amplifier
V5269	Assistive listening device, alerting
V5270	Assistive listening device, television amplifier
V5281	Assistive listening device, personal FM/DM system, monaural
V5282	Assistive listening device, personal FM/DM system binaural

Code not separately reimbursedCPTNot Covered

S0618

Audiometry for hearing aid evaluation to determine the level and degree of hearing loss

inv-09: Coverage amount per aid — $1,500 (under 19 years) / $700 (19 years and older)

Coverage amount per individual aid (age <19)$1,500 per aid, per occurrence (for individuals under 19 years)

Coverage amount per individual aid (age ≥19)$700 per aid, per occurrence (for individuals 19 years and older)

ApplicabilityApplies to Commercial products only; benefits may vary by group—see member Evidence of Coverage or Benefit Booklet

inv-10: Replacement frequency — per occurrence / typically not more than once every 3 years

Replacement frequency (typical)Typically not necessary more than once every 3 years

Replacement frequency (per occurrence)Replacements are considered on a per occurrence basis

Policy notePolicy references a typical 3-year replacement expectation but does not impose a step therapy requirement; check member documents for benefit determination

Provider actions and billing guidance

Prior Authorization

Prior authorization

Prior authorization review is not required for hearing aids under this policy for Commercial products.

Note

Replacement interval

Please note: it is not typically necessary to replace a hearing aid more than once every three years. Replacement requests submitted more frequently should include supporting clinical documentation demonstrating medical necessity for earlier replacement; no step therapy is imposed.

Documentation Required

Unlisted code documentation

Unlisted HCPCS codes (for example V5090, V5298, V5299 and other unlisted dispensing or hearing aid codes) follow the unlisted code review process and require submission of supporting documentation to justify medical necessity, item description, and cost. Failure to submit adequate documentation may result in claim denial or processing delays.

Affected HCPCS examples: V5090, V5298, V5299

Denial Risk

Non‑covered codes may lead to denial

Certain CPT and HCPCS codes are explicitly non‑covered and may lead to denial if billed under the hearing aid benefit (see the policy's non‑covered code list). Examples include hearing aid examination/selection and many assistive-listening device supply codes.

Non‑covered examples include: 92590–92595; V5011; V5014; V5020; V5110; V5160; V5200; V5240; V5241; and multiple V52xx assistive listening device codes

Background

Hearing aids are wearable devices intended to compensate for impaired hearing. Under Rhode Island statute and this policy, a "hearing aid" means any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of or compensating for impaired human hearing, with exclusions as noted above. The statute establishes age‑based coverage limits and replacement guidance that this policy implements for Commercial products: coverage amounts are set per occurrence (for example, up to $1,500 per aid for members under 19 years and up to $700 per aid for members 19 years and older), and replacement is typically not expected more often than once every 3 years.

Definitions

inv-16: hearing aid — definition of 'Hearing aid' per policy

Definition'Hearing aid' means any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices (including, but not limited to, FM systems)

ScopeThis policy applies only to external hearing aids as defined by the mandate

ExclusionsBatteries, cords, and other assistive listening devices (e.g., FM systems) are excluded from the hearing aid definition and benefit