Prior authorization: speech perception documentation

Prior approval is required. Include objective speech-perception test results (aided and unaided) with the prior authorization request. Documentation should show developmentally appropriate open-set or monosyllabic word lists (e.g., CNC, PBK) with scores for the ear to be implanted or replaced.

• Provide audiometric thresholds and aided speech-perception (open-set) scores.
• Include date the device was received and manufacturer warranty information showing the current device is not under warranty.

Authorization tied to audiologic thresholds

Authorization decisions are tied to specific audiologic thresholds and documented speech-recognition performance. Requests should demonstrate that the individual meets the policy’s audiologic and speech-recognition thresholds (for example, poor open-set word-recognition scores as described below) and that replacement is expected to improve function.

• Document pre-authorization audiologic thresholds and aided word-recognition percentages in the ear to be implanted or replaced.
• State the expected functional improvement with a replacement device.

Word-recognition threshold not met

If the documented word-recognition scores do not meet the policy’s required thresholds (for example, not showing <12% or <30% on the applicable open-set measures where specified), the request risks denial.

• Failure to demonstrate qualifying low open-set word-recognition scores (as required by age/measure) may result in denial.
• If aided speech perception scores exceed the policy thresholds, include rationale for why replacement is still medically necessary.

Speech test documentation risk

Not documenting qualifying speech-recognition test results, or omitting the specific test name, raw score, test conditions (ear tested, aided/unaided), and date, increases the likelihood of denial. Provide full test reports with interpretation.

• Include test name (e.g., CNC, PBK), percent correct, ear tested, aided vs unaided condition, and test date.
• Report if developmentally appropriate test materials were used for children.

Required documentation

Provide complete objective documentation to support medical necessity for replacement. Required items include device receipt date, manufacturer warranty showing device is not under warranty, objective evidence device is non-repairable, and evidence device use was daily until malfunction.

• Date device was received.
• Manufacturer warranty information indicating the device is not under warranty.
• Audiologist documentation describing why the device is non-repairable/malfunctioning.
• Statement that the device was used daily until malfunction and is interfering with activities of daily living.
• Evidence there is no loss, abuse, or neglect of the device.
• Documentation of patient compliance with device use and anticipated continued benefit.

Documented speech perception test results

Document speech-perception test results using developmentally appropriate monosyllabic/open-set lists in the ear to be implanted; report percent-correct scores and test conditions.

• Use appropriate word lists (e.g., CNC, PBK) for age and development.
• Report open-set percent-correct scores for the ear to be implanted/replaced and indicate aided vs unaided performance.

Audiologic testing and device experience

Audiologic testing must include aided speech-recognition testing and documentation of trials with appropriate alternative devices when applicable. Record the duration and outcomes of any hearing-aid or CROS trials.

• Include aided and unaided audiograms and speech-recognition testing.
• Document trials of appropriately fitted hearing aids or CROS devices (typically at least 1 month) and the limited benefit observed.
• State whether alternative amplification provided functional improvement and include measured scores.

Required test and device-use documentation

Record open-set percent scores, PBK or equivalent test notation, and prior device-use history. For children and adults, include the specific scores that demonstrate limited benefit from hearing aids or other strategies.

• Open-set percent-correct scores and the specific test used (e.g., PBK for children).
• Notation of duration of hearing-aid or CROS use (e.g., ≥1 month) and summary of benefit (limited vs meaningful).
• Documentation that replacement is not solely for upgraded technology or aesthetics and that device is non-repairable.

Use appropriate CPT and HCPCS codes when reporting services

Report services and replacement components using the CPT and HCPCS codes listed in the policy. Use unlisted procedure code 69949 when specifying implantation of a hybrid cochlear device and the appropriate L‑series HCPCS codes for external components and replacements.

• Use CPT codes appropriate to the surgical service; when implanting a hybrid cochlear device specify 69949 (unlisted procedure, inner ear) as indicated.
• Use HCPCS L8615–L8629 and L8699 for external speech processors, components, transmitting coils/cables, microphones, and prosthetic implants as applicable.

Evidence of trial and limited benefit from appropriately fitted hearing aids

Provide evidence of a trial and limited benefit from an appropriately fitted hearing aid or alternative amplification before implantation/replacement when required by the policy. Document the trial details and measured outcomes.

• Document at least a 1‑month trial of an appropriately fitted hearing aid or CROS when policy criteria require it.
• Include aided speech-recognition scores demonstrating limited benefit despite the trial.

Trial of alternative hearing strategies

When applicable, document attempts at alternative hearing strategies (e.g., CROS, bilateral hearing aids) and their outcomes prior to approving replacement. Include objective speech-recognition scores showing limited benefit from these strategies.

• Describe alternative strategies tried (CROS, bilateral hearing aids) and duration of use.
• Supply objective aided speech-recognition data showing limited benefit from alternatives.