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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)CenCal Health Hearing Aid Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentCenCal HealthPolicy N/A

    Authorization Guidelines for Hearing Aids

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    This policy governs CenCal Health authorization, medical-necessity documentation, coding, and submission requirements for hearing aids, replacements, repairs, programmable or digital systems, and related supplies or accessories.

    Policy Summary
    PayerCenCal Health
    PolicyAuthorization Guidelines for Hearing Aids
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit a TAR or AR for all new hearing aids and applicable replacement, purchase, trial rental, and repair requests exceeding $25.00 per repair service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    All new hearing aidsServices requiring a TAR/AR
    $25.00Repair-cost threshold requiring a TAR/AR
    3 monthsMaximum age of current audiogram for specified replacements
    14 daysPlan timeframe for initial authorization determination

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5 business days
    Health Services processing timeframe
    Not coveredReplacement hearing aid batteries

    Hearing Aid Coverage Criteria

    New hearing aids

    Covered when all of the following are met, including either audiogram pathway:

    New hearing aid medical necessity

    • Audiogram hearing-loss pathway

      • Primary audiogram threshold: The average hearing loss level is 35 dB or greater at 500, 1000, and 5000 Hz≥35 dB at 500, 1000, and 5000 Hz
      • Alternative audiogram threshold: The average hearing loss level is 30 dB and the difference between the levels at 1000 Hz and 2000 Hz is 20 dB or more30 dB average; 1000-to-2000 Hz difference ≥20 dB
    • Functional benefit: The member's communication or safety is effectively improved with hearing aids through auditory contact
    • Fitting specification: The ear to be fitted is specified
    • Prescription: A prescription signed and dated by the physician is provided

    Replacement for loss, theft, or irreparable damage

    Covered when all applicable conditions and documentation requirements are met:

    Lost, stolen, or irreparably damaged replacement

    • Event documentation: A detailed description of the events leading to the loss or damage is signed by the member and physician

    • Audiogram currency

      • Current audiogram: A current audiogram is provided that is no more than three months old≤3 months old
      • Updated audiogram: If the existing audiogram is more than three months old, a current audiogram is provided using the specifications for new hearing aids

        Applies when the existing audiogram is older than three months.

    Replacement hearing aids that no longer meet needs

    Covered when comparative clinical documentation demonstrates that the replacement hearing aid is needed:

    Replacement due to changed needs

    • Comparative audiograms based on the new-hearing-aid specifications are provided and are used for fitting both the old and new hearing aids

    Programmable or digital hearing aid systems

    Replacement of a lost, stolen, or irreparably damaged programmable or digital hearing aid is covered when all of the following are met:

    Programmable or digital replacement

    • Loss-and-damage feature: The loss-and-damage feature was included in the purchase price
    • Feature documentation: Documentation is provided indicating that the loss-and-damage feature was included in the purchase price
    • Device identification: The hearing aid manufacturer name and the model or serial number are provided
    • Replacement fee: The replacement fee is provided

    Replacement hearing aid batteries are not covered.

    Covered Codes and Operational Thresholds

    Ear moldsHCPCSCovered
    V5264Ear molds
    V5265Ear molds
    V6265Ear molds
    V5364Ear molds
    Programmable or Digital Hearing Aid SystemsHCPCSCovered
    V5298Programmable or Digital Hearing Aid Systems
    Hearing Aid Supplies/AccessoriesHCPCSCovered
    V5267Hearing Aid Supplies/Accessories
    New Hearing Aid Hearing-Loss Criterion
    Average hearing loss35 dB or greater
    Required frequencies500, 1000, and 5000 Hz
    Applies toNew hearing aid authorization documentation
    Alternative New Hearing Aid Criterion
    Average hearing loss30 dB
    Inter-frequency differenceThe difference between the levels at 1000 Hz and 2000 Hz is 20 dB or more
    Applies to

    Authorization and Documentation Requirements

    Prior Authorization

    TAR or AR Required

    A Treatment Authorization Request (TAR) or Authorization Request (AR) is required before processing new hearing aids, replacement hearing aids, hearing-aid purchase or trial rental periods, and repairs exceeding $25.00 per repair service.

    • Ear molds (V5264 and V6265) do not require prior authorization.
    • A TAR/AR is required for replacement of lost, stolen, or damaged hearing aids and for hearing aids that no longer meet the member’s needs.
    • Hearing aids are not a Medicare benefit; a Medicare denial letter is not required.
    Documentation Required

    Written Prescription Required

    Obtain a written prescription for all hearing aid appliances, except ear molds. For an initial purchase request, submit the prescription with the authorization; for replacement and repair requests, retain it in the member’s medical chart for plan audit.

    Policy Summary
    PayerCenCal Health
    PolicyAuthorization Guidelines for Hearing Aids
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit a TAR or AR for all new hearing aids and applicable replacement, purchase, trial rental, and repair requests exceeding $25.00 per repair service.
    SourceLink
    On This Page
    Hearing Aid Coverage CriteriaCovered Codes and Operational ThresholdsAuthorization and Documentation Requirements
  1. Warranty damage documentation: If the hearing aid is under warranty but irreparably damaged, the manufacturer provides a statement that the aid is not repairable and replacement is requested

    Applies when the hearing aid is under warranty and irreparably damaged.

    2. Alternative new hearing aid audiogram criterion
    Hearing Aid Repair Authorization Threshold
    Authorization thresholdRepair service exceeds $25.00
    Request typeTreatment Authorization Request (TAR) or Authorization Request (AR)
    Required repair documentationWritten problem description, ear to be fitted, and manufacturer, unit, model, purchase date, and serial number
    Current Audiogram Requirement
    Audiogram ageNo more than three (3) months old
    Applies toReplacement of lost, stolen, or irreparably damaged hearing aids
    If older than three monthsProvide a current audiogram based on the New Hearing Aids specifications
    Initial Authorization Determination
    Initial determination timeframeFourteen (14) calendar days
    Determining entityCenCal Health
    Applies toMedical authorization initial determinations
    Health Services Processing Timeframe
    Processing timeframeWithin five (5) business days
    Time beginsUpon receipt of the authorization and all necessary documentation
    Responsible departmentHealth Services
  2. The prescription must be signed and dated by the physician for new hearing aid requests.
  3. Ear molds are excepted from the written-prescription requirement (V5264 and V5265).
    4. Documentation Required

    New Hearing Aid Documentation

    For a new hearing aid TAR/AR, submit documentation establishing medical necessity, including the signed and dated physician prescription, a qualifying audiogram, communication or safety improvement with hearing aids, and the ear to be fitted.

    • Audiogram: average hearing loss of at least 35 dB at 500, 1000, and 5000 Hz; or average hearing loss of at least 30 dB when the difference between 1000 Hz and 2000 Hz is 20 dB or more.
    • Document that the member’s communication or safety is effectively improved through auditory contact with hearing aids.
    • Specify the ear to be fitted.
    Documentation Required

    Lost, Stolen, or Damaged Replacement Documentation

    For replacement of a lost, stolen, or irreparably damaged hearing aid, submit a signed description of the events leading to the loss or damage from both the member and physician, along with the required current clinical documentation.

    • Provide a current audiogram no more than three months old. If older than three months, provide a current audiogram meeting the New Hearing Aids specifications.
    • If the aid is under warranty but irreparably damaged, provide the manufacturer’s statement that it is not repairable and that replacement is requested.
    Documentation Required

    Replacement Due to Changed Needs

    For replacement because the hearing aid no longer meets the member’s needs, submit comparative audiograms meeting the New Hearing Aids specifications for fitting both the old and new hearing aids.

    • The comparative audiograms must support the need for the proposed replacement.
    Documentation Required

    Repair Documentation Over $25

    For a hearing aid repair exceeding $25.00 per repair service, submit documentation describing the problem and identifying the hearing aid and fitting details.

    • Written description of the problem requiring repair.
    • Specification of the ear to be fitted.
    • Manufacturer name, unit, model designation, date of purchase, and serial number.

    Unsupported block type: documentation

    Prior Authorization

    Programmable or Digital Replacement Documentation

    A programmable or digital hearing aid lost, stolen, or irreparably damaged may be replaced only when a loss-and-damage feature was included in the purchase price.

    • Submit documentation showing that the loss-and-damage feature was included.
    • Provide the manufacturer name, model or serial number, and replacement fee.
    Documentation Required

    Supply and Accessory Documentation

    For hearing aid supplies or accessories (V5267), include identifying information and wholesale pricing documentation with the submission.

    • Provide the supply or accessory manufacturer name and model number.
    • Include a copy of the wholesale catalog page showing the supply or accessory description and manufacturer price.
    Prior Authorization

    TAR/AR Submission Requirements

    Submit all required supporting documentation with the TAR/AR. For website submissions, fax the documentation to CenCal Health on the same day and place the TAR/AR number on every page so the materials are attached to the correct authorization.

    • Paper authorization forms should be mailed or faxed with all supporting documentation included.
    • Submit a quantity of one for hearing aid appliances, except ear molds (V5364 and V5265); appliance procedure codes already reflect monaural or binaural use.
    • CenCal Health has 14 calendar days to make an initial determination; Health Services processes authorizations within five business days after receiving the authorization and all necessary documentation.
    • If required documentation will be delayed, notify Health Services at (805) 562-1082 or the plan staff member requesting the documentation.
    • Email is the most effective means of communication for authorizations; contact Provider Services at (805) 562-1676 to receive authorization email notifications or update the email address.
    Denial Risk

    Replacement Batteries Not Covered

    Replacement hearing aid batteries are not covered by CenCal Health.

    Denial Risk

    Loss-and-Damage Feature Required

    Replacement of a lost, stolen, or irreparably damaged programmable or digital hearing aid requires that a loss-and-damage feature was included in the original purchase price.

    • Without documentation that the loss-and-damage feature was included, the replacement request does not meet this requirement.