CurrentEmblemHealthPolicy MG.MM.ME.33bC2

Otoacoustic Emissions Testing

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Clinical coverage criteria and coding guidance for otoacoustic emissions (OAE) screening and diagnostic testing for EmblemHealth members, including indications, limitations, and applicable procedure and diagnosis codes; intended for providers requesting authorization or submitting claims.

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CurrentEmblemHealthPolicy MG.MM.ME.33bC2

Otoacoustic Emissions Testing

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Policy Summary

PayerEmblemHealth

PolicyOtoacoustic Emissions Testing

Policy CodePolicy MG.MM.ME.33bC2

Change TypeNo material changes

Effective Date

Last ReviewApr 11, 2025

Next Review DateApr 11, 2025

Key ActionProviders must submit clinical documentation that the member meets the policy criteria when requesting authorization for CPT codes 92558, 92587, and 92588.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT codes addressed

~70+ICD-10 codes listed

90 daysNeonatal screening age threshold

3 yearsScreening age when audiometry not feasible

ExtensiveCode coverage scope

Coverage Criteria for OAE Screening and Diagnostic Testing

inv-01: Screening indications (92558) — covered indications

Covered when ALL of the following are met:

Screening (CPT 92558): Neonatal hearing screening using otoacoustic emissions (OAE) is medically necessary for infants 90 days of age or younger.age <= 90 days for neonatal screening

Use CPT 92558 for OAE screening

Screening (CPT 92558) — alternate pediatric indication: Evoked OAE is medically necessary to screen children 3 years of age and younger who did not have initial neonatal screening and/or cannot be effectively measured or monitored through conventional audiometry.age <= 3 years when audiometry not feasible

Use CPT 92558 for OAE screening

inv-02: Diagnostic indications (92587, 92588) — diagnostic evaluations

Covered diagnostic evaluations (use CPT 92587 for limited and CPT 92588 for comprehensive testing):

Diagnostic indications (CPT 92587, 92588): Infants over 90 days and children up to 4 years of age.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Children and adults who are unable to cooperate with other methods of hearing testing (for example, individuals with autism or stroke).

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Children with developmental or delayed speech or language disorders.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Individuals with tinnitus, acoustic trauma, noise-induced hearing loss, or sudden hearing loss.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Routine evoked otoacoustic emissions screening (CPT 92558) performed at well‑child visits for children age 3 years who have passed the newborn hearing screen is not medically necessary unless the child has a documented risk factor for hearing loss, demonstrated impairment of speech or auditory skills, or abnormal middle ear status. This limitation applies to screening OAE performed solely as part of routine well‑child care in the absence of those specified clinical concerns.

Comprehensive otoacoustic emissions testing (CPT 92588) is considered experimental and investigational and not medically necessary when used for initial hearing screening because available evidence does not demonstrate added value of comprehensive testing over limited/ screening OAE for that indication.

Auditory screening or diagnostic testing using otoacoustic emissions (OAEs) is considered unproven and not medically necessary for populations and clinical conditions that are not explicitly listed as covered indications in this policy. The policy notes inadequate evidence that OAE screening or diagnostic OAE testing improves health outcomes compared with standard screening audiometry for groups not specified as medically necessary.

No explicit exclusions beyond the listed limitations are stated in the portions of the policy that enumerate applicable diagnosis codes and related code lists. Providers should use the diagnosis codes shown in the policy to support medical‑necessity determinations where applicable.

This section of the document does not list any additional explicit exclusions beyond those identified under Limitations/Exclusions; absence of further exclusions in this portion does not alter the coverage limitations stated elsewhere in the policy.

Specifically, routine evoked OAE screening (CPT 92558) at well‑child visits for children aged 3 years or younger who have passed the newborn screen is designated not medically necessary unless one of the policy’s exceptions is present (risk factor for hearing loss, speech/auditory impairment, or abnormal middle ear status). When such exceptions exist, screening may be appropriate and should be documented.

Comprehensive OAE testing (CPT 92588) is explicitly identified as experimental/investigational and not medically necessary when used for initial screening, given lack of evidence demonstrating benefit beyond limited or screening OAE approaches for that purpose.

Some document sections that list applicable ICD‑10 diagnosis codes do not include additional explicit 'not medically necessary' statements; those lists are intended to provide diagnosis coding that may support medical‑necessity determinations when the policy criteria are met.

Procedure and Diagnosis Codes

Applicable Procedure CodesCPT

92558	Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis.
92587	Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report.
92588	Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report.

Applicable ICD-10 Diagnosis Codes (partial list)ICD-10

A17.0	Tuberculous meningitis
A39.0	Meningococcal meningitis
A52.13	Late syphilitic meningitis
A80.0	Acute paralytic poliomyelitis, vaccine-associated
A80.1	Acute paralytic poliomyelitis, wild virus, imported
A80.2	Acute paralytic poliomyelitis, wild virus, indigenous
A80.30	Acute paralytic poliomyelitis, unspecified
A80.39	Other acute paralytic poliomyelitis
A80.9	Acute poliomyelitis, unspecified
A87.0	Enteroviral meningitis

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Applicable ICD-10 Hearing Loss/Ototoxicity/Sudden Hearing Loss CodesICD-10

H90.8	Mixed conductive and sensorineural hearing loss, unspecified
H90.A11	Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A12	Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side
H90.A21	Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side
H90.A22	Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side
H90.A31	Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A32	Mixed conductive and sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side
H91.01	Ototoxic hearing loss, right ear
H91.02	Ototoxic hearing loss, left ear
H91.03	Ototoxic hearing loss, bilateral

1–10 of 15

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Applicable ICD-10 Tinnitus/Other Auditory Perception CodesICD-10

H91.8X1	Other specified hearing loss, right ear
H91.8X2	Other specified hearing loss, left ear
H91.8X3	Other specified hearing loss, bilateral
H91.8X9	Other specified hearing loss, unspecified ear
H93.011	Transient ischemic deafness, right ear
H93.012	Transient ischemic deafness, left ear
H93.013	Transient ischemic deafness, bilateral
H93.019	Transient ischemic deafness, unspecified ear
H93.11	Tinnitus, right ear
H93.12	Tinnitus, left ear

1–10 of 12

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Applicable ICD-10 Auditory Perception/Hyperacusis/Diplacusis CodesICD-10

H93.211	Auditory recruitment, right ear
H93.212	Auditory recruitment, left ear
H93.213	Auditory recruitment, bilateral
H93.219	Auditory recruitment, unspecified ear
H93.221	Diplacusis, right ear
H93.222	Diplacusis, left ear
H93.223	Diplacusis, bilateral
H93.229	Diplacusis, unspecified ear
H93.231	Hyperacusis, right ear
H93.232	Hyperacusis, left ear

1–10 of 12

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Additional Auditory Disorder CodesICD-10

H93.241	Temporary auditory threshold shift, right ear
H93.242	Temporary auditory threshold shift, left ear
H93.243	Temporary auditory threshold shift, bilateral
H93.249	Temporary auditory threshold shift, unspecified ear
H93.25	Central auditory processing disorder
H93.291	Other abnormal auditory perceptions, right ear
H93.292	Other abnormal auditory perceptions, left ear
H93.293	Other abnormal auditory perceptions, bilateral
H93.299	Other abnormal auditory perceptions, unspecified ear
H93.A1	Pulsatile tinnitus, right ear

1–10 of 13

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Cerebrovascular Codes Related to Auditory/Neurologic SequelaeICD-10

I67.2	Cerebral atherosclerosis
I67.81	Acute cerebrovascular insufficiency
I67.82	Cerebral ischemia
I67.850	Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
I67.89	Other cerebrovascular disease
I68.0	Cerebral amyloid angiopathy

Sequelae of Cerebrovascular Disease CodesICD-10

I69.00	Unspecified sequelae of nontraumatic subarachnoid hemorrhage
I69.010	Attention and concentration deficit following nontraumatic subarachnoid hemorrhage
I69.011	Memory deficit following nontraumatic subarachnoid hemorrhage
I69.012	Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage

Screening and Encounter Z-codesICD-10

Z01.110	Encounter for hearing examination following failed hearing screening
Z01.118	Encounter for examination of ears and hearing with other abnormal findings
Z13.40	Encounter for screening for unspecified developmental delays
Z13.41	Encounter for autism screening
Z13.42	Encounter for screening for global developmental delays (milestones)
Z13.49	Encounter for screening for other developmental delays
Z13.5	Encounter for screening for eye and ear disorders

Trauma to Ear Drum CodesICD-10

S09.20XA	Traumatic rupture of unspecified ear drum, initial encounter
S09.21XA	Traumatic rupture of right ear drum, initial encounter
S09.22XA	Traumatic rupture of left ear drum, initial encounter

Neonatal, Genetic, Symptom, Toxicity and Other Relevant CodesICD-10

P11.1	Other specified brain damage due to birth injury
P11.2	Unspecified brain damage due to birth injury
Q90.0	Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q90.1	Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2	Trisomy 21, translocation
Q90.9	Down syndrome, unspecified
R42	Dizziness and giddiness
R94.120	Abnormal auditory function study
T36.5X1A	Poisoning by aminoglycosides, accidental (unintentional), initial encounter
T36.5X5A	Adverse effect of aminoglycosides, initial encounter

1–10 of 11

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Medication-related Toxicity and History CodesICD-10

T36.8X1A	Poisoning by other systemic antibiotics, accidental, initial encounter
T45.1X1A	Poisoning by antineoplastic and immunosuppressive drugs, accidental, initial encounter
Z92.21	Personal history of antineoplastic chemotherapy

Applicable ICD-10 Diagnosis CodesICD-10

T36.5X3A	Poisoning by aminoglycosides, assault, initial encounter
T36.5X3D	Poisoning by aminoglycosides, assault, subsequent encounter
T36.5X3S	Poisoning by aminoglycosides, assault, sequela
T36.5X4A	Poisoning by aminoglycosides, undetermined, initial encounter
T36.5X4D	Poisoning by aminoglycosides, undetermined, subsequent encounter
T36.5X4S	Poisoning by aminoglycosides, undetermined, sequela
T36.5X5A	Adverse effect of aminoglycosides, initial encounter
T36.5X5D	Adverse effect of aminoglycosides, subsequent encounter
T36.5X5S	Adverse effect of aminoglycosides, sequela
T36.6X1A	Poisoning by rifampicins, accidental, initial encounter

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Provider Requirements and Prior Authorization

Prior Authorization

Authorization requirement — submit clinical documentation

Providers must submit clinical documentation that the member meets the policy criteria when requesting authorization for CPT codes 92558 (screening), 92587 (limited diagnostic), and 92588 (comprehensive diagnostic).

Applicable CPT codes: 92558, 92587, 92588

Prior Authorization

Prior authorization — include an applicable ICD-10 diagnosis code

The policy lists applicable ICD-10 diagnosis codes that may support coverage determinations for OAE services; include one of the listed ICD-10 codes on authorization requests and claims as applicable.

See ICD-10 lists in the policy (e.g., H90.8, H91.01–H91.03, H93.11, Z01.110, Z01.118, T36.x/T45.x series).

Prior Authorization

Background and Scope

Otoacoustic emissions (OAEs) are low‑amplitude sounds generated by healthy cochlear outer hair cells in response to acoustic stimulation. OAEs are recorded with a lightweight ear‑canal probe that presents stimuli (clicks for transient‑evoked OAEs; tones for distortion‑product OAEs) and uses a microphone to average multiple responses into a repeatable waveform. OAEs assess cochlear (outer hair cell) function and are used for newborn and early‑childhood screening, for patients unable to cooperate with behavioral audiometry, for tinnitus evaluation, suspected malingering, and for monitoring cochlear damage from ototoxic medications. OAEs do not assess neural transmission and may miss auditory neuropathy; auditory brainstem response (ABR) testing may be required for definitive evaluation in some clinical contexts.

Definitions and Test Types

Transient evoked otoacoustic emissions (TEOAE) — definition and use in screening

DefinitionTransient evoked otoacoustic emissions (TEOAE): OAEs generated in response to wide-band clicks recorded via an ear‑canal probe to assess cochlear (outer hair cell) function.

Primary useUsed as a screening tool for newborns and young children and for patients unable to complete behavioral audiometry.

Test methodA light‑weight ear canal probe presents click stimuli and a microphone records averaged responses to produce repeatable waveforms.

Clinical contextsEmployed for newborn/early‑childhood hearing screening, evaluation of tinnitus, suspected malingering, and monitoring cochlear damage from ototoxic drugs.

LimitationsTEOAEs assess cochlear function but do not evaluate neural transmission and can miss auditory neuropathy; ABR may be required for definitive testing.

Policy Summary

PayerEmblemHealth

PolicyOtoacoustic Emissions Testing

Policy CodePolicy MG.MM.ME.33bC2

Change TypeNo material changes

Effective Date

Last ReviewApr 11, 2025

Next Review DateApr 11, 2025

Key ActionProviders must submit clinical documentation that the member meets the policy criteria when requesting authorization for CPT codes 92558, 92587, and 92588.

SourceLink

On This Page

Diagnostic indications (CPT 92587, 92588): Individuals with auditory neuropathy spectrum disorder (ANSD) or auditory processing disorder (APD).

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Individuals with known or suspected sensorineural hearing loss.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Individuals with abnormal auditory function studies or a failed hearing exam.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Individuals suspected of feigning hearing loss.

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Diagnostic indications (CPT 92587, 92588): Monitoring of ototoxicity before, during, and after administration of agents known to be ototoxic (for example, aminoglycosides or chemotherapy agents).

Use CPT 92587 for limited evaluation and CPT 92588 for comprehensive diagnostic evaluation

Use an appropriate listed ICD-10 diagnosis code

When prior authorization is required, use an appropriate ICD-10 diagnosis code from the policy’s listed codes to support medical necessity for the requested OAE testing.

Examples include hearing loss/ototoxicity codes (H91.x), screening/follow-up Z-codes (Z01.110, Z01.118), and toxicity/history codes (T36.5X5A, Z92.21).

Step Therapy

Screening protocol note — OAE then ABR for failures

Newborn hearing screening programs commonly use a one-step or two-step validated protocol, frequently involving OAE followed by ABR for those who fail the first test.

Ensure protocols for follow-up evaluation and screening before one month of age; infants who fail should have audiologic and medical evaluation before 3 months of age.

Note

No additional provider actions specified in these sections

No specific provider action is labeled in this portion of the policy beyond the requirements to submit documentation and appropriate diagnosis codes; include encounter and diagnosis codes as applicable on requests and claims.

If no prior authorization text applies, rely on listed ICD-10 codes to document medical necessity.

Note

No further provider actions specified here

No additional specific provider actions were specified in these chunks; follow the authorization and documentation requirements already stated in the policy when submitting requests.

Include relevant diagnosis and history codes from the lists when applicable.

Documentation Required

Submit clinical evidence from treating physician or PCP

The treating physician or primary care provider must submit clinical evidence demonstrating the member meets the policy criteria for the requested OAE service to enable preauthorization or post-payment review.

Clinical evidence should document the indication (e.g., failed newborn screen, developmental concerns, ototoxic exposure) that meets the policy criteria.

Documentation Required

Encounter and screening diagnosis codes — listed for support

Encounter and screening diagnosis codes that would support documentation for screening and follow-up are listed in the policy but specific encounter-only requirements are not otherwise specified in these chunks.

Relevant Z-codes include Z01.110 (hearing exam following failed screening), Z01.118 (exam of ears/hearing with abnormal findings), Z13.4x/Z13.5 series.

Documentation Required

Include encounter and history diagnosis codes (Z-codes)

Include relevant encounter and history diagnosis codes on authorization requests and claims where applicable, for example Z01.110, Z01.118, and Z92.21 to support the clinical context.

Z01.110 — Encounter for hearing exam following failed screening
Z01.118 — Encounter for exam of ears/hearing with other abnormal findings
Z92.21 — Personal history of antineoplastic chemotherapy

Denial Risk

Documentation requirement — submit required clinical evidence

Failure to submit the clinical evidence that the member meets the policy criteria will prevent EmblemHealth from properly reviewing the preauthorization or post-payment request.

Ensure documentation clearly demonstrates the covered indication per the policy (e.g., neonatal screen failure, ototoxicity monitoring).

Denial Risk

No additional denial triggers specified here

No specific denial triggers beyond documentation and coding requirements are specified in these chunks; denial triggers are not present in this document portion.

Continue to follow the policy documentation and coding guidance to avoid denial risk.

Denial Risk

Diagnosis code documentation risk — include a listed ICD-10 code

Claims or authorization requests that lack an applicable ICD-10 diagnosis code from the policy’s listed codes (for example, hearing screening follow-up, ototoxicity, or exposure/toxicity codes) may be at risk for denial if documentation does not support medical necessity.

Verify that the claim/authorization includes a diagnosis from the policy lists (e.g., H91.x series, H90.A21–A22, T36.5X5A, Z01.110).

Distortion product otoacoustic emissions (DPOAE) — definition and use for diagnostic evaluation

DefinitionDistortion product otoacoustic emissions (DPOAE): OAEs produced in response to tones (two simultaneous pure‑tone stimuli) recorded via an ear‑canal probe to evaluate cochlear (outer hair cell) function.

Primary useUsed for diagnostic evaluation of cochlear function, including limited (92587) and comprehensive (92588) otoacoustic emission testing.

Test methodTone‑pair stimuli are presented through a probe and resulting emissions are recorded and averaged to generate frequency‑specific responses.

Clinical contextsApplied when more frequency‑specific diagnostic information is needed (e.g., suspected sensorineural loss, ototoxicity monitoring, cases where audiometry is not feasible).

LimitationsLike other OAEs, DPOAEs do not assess neural pathways and may miss neural auditory disorders; ABR may be necessary for comprehensive evaluation.

Hearing loss and related auditory disorder diagnosis codes (examples)

Examples (mixed and conductive/sensorineural)H90.8 — Mixed conductive and sensorineural hearing loss, unspecified.

Conductive and sensorineural subtypesH90.A11, H90.A12, H90.A21, H90.A22, H90.A31, H90.A32 — Unilateral and mixed hearing loss subcategories.

Ototoxic and sudden lossH91.01–H91.03, H91.09, H91.20–H91.23 — Ototoxic hearing loss and sudden idiopathic hearing loss codes.

Other specified hearing lossH91.8X1–H91.8X9 — Other specified hearing loss (right, left, bilateral, unspecified).

Auditory/vestibular perceptionsH93.011–H93.019, H93.11–H93.19 — Transient ischemic deafness and tinnitus codes.

Screening/encounter and history codes relevant to hearing screening and follow-up

Encounter for failed screeningZ01.110 — Encounter for hearing examination following failed hearing screening.

Encounter with abnormal findingsZ01.118 — Encounter for examination of ears and hearing with other abnormal findings.

Developmental screening seriesZ13.40–Z13.49 — Encounters for screening for developmental delays (unspecified, autism, global, other).

Screening for eye/ear disordersZ13.5 — Encounter for screening for eye and ear disorders.

History of chemotherapyZ92.21 — Personal history of antineoplastic chemotherapy (relevant for ototoxicity monitoring).

Ototoxicity monitoring — definition describing systematic audiologic surveillance for patients exposed to ototoxic medications

DefinitionOtotoxicity monitoring: systematic audiologic surveillance of patients exposed to ototoxic medications to detect early cochlear dysfunction.

PurposeDetect early changes in cochlear (outer hair cell) function to allow intervention (medication adjustment or alternative therapies) to limit permanent hearing loss.

Methods usedMonitoring commonly uses OAEs (DPOAE/TEOAE) and/or audiometry; OAEs are useful when behavioral audiometry is not feasible.

Relevant guidanceProfessional guidance on ototoxicity monitoring is provided by the American Academy of Audiology (Ototoxicity Monitoring, 2009).

Clinical applicationApplicable for patients receiving known ototoxic agents (e.g., aminoglycosides, antineoplastic drugs) and documented using appropriate ICD‑10 toxicity/history codes.