CurrentFidelis CarePolicy CP.MP.93

Bone-Anchored Hearing Aid (BAHA) Coverage

Defines medical necessity criteria, replacement rules, and coding references for bone-anchored hearing aids and external components for Fidelis Care members.

Policy Summary

PayerFidelis Care

PolicyBone-Anchored Hearing Aid (BAHA) Coverage

Policy CodePolicy CP.MP.93

Change TypeCriteria clarifications and threshold refinements

Effective Date

Next Review Date

Key ActionObtain prior authorization and document patient age, device type, audiometric data (PTA bone conduction at 0.5,1,2,3 kHz), unaided SDS, laterality, and device age/repairability when requesting implantation or replacement.

SourceLink

POLICY UPDATE CHANGES

Added criteria to I.B. 'where the condition prevents restoration of hearing…'.

Updated criteria in I.C. to specify 'is consistent with the FDA indications for the requested device'.

Revised I.E from 'threshold of 20dB' to 'threshold of < 20dB.'

≥5minimum age for implantable device

SDS ≥60%speech discrimination score

<10max bilateral diff (dB)

<20unilateral hearing ear threshold (dB)

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Coverage and Medical Necessity Criteria

Initial Implantation / Headband Coverage

Covered when ALL of the following are met:

Age/device: Implantable device for age ≥ five years; or head band device for age < five years or medically unable to have an implant

children usually around six years before implant feasible due to bone thickness

Type of hearing loss: Unilateral or bilateral conductive and/or mixed hearing loss or unilateral sensorineural hearing loss where the condition prevents restoration of hearing using a conventional air-conductive hearing aid

added phrasing to I.B.

Audiometry: Pure tone average bone conduction threshold (measured at 0.5, 1, 2, and 3 kHz) consistent with the FDA indications for the requested device AND unaided speech discrimination score ≥ 60%SDS ≥ 60%

ties threshold to FDA device indications

Bilateral fit: For bilateral BAHA, mean maximum difference <10 dB between right and left bone conduction thresholds<10 dB

Unilateral deafness: For unilateral deafness, the hearing ear should have a bone conduction threshold of < 20 dB<20 dB

Specific indications: One of the following: congenital or surgically induced malformation of ear canal (provided nerve functional); chronic infection or dermatitis exacerbated by standard air-conduction hearing aid; allergic reactions to standard air-conduction hearing aids; unilateral deafness due to acoustic neuroma removal, trauma, viral/vascular insult, or idiopathic causes; tumors of external canal and/or tympanic cavity; or air-conduction hearing aid ineffective due to large conductive hearing loss

Replacement Criteria

Replacement of BAHA device or external sound processor is covered when ANY of the following are met:

Non-repairable: Existing device(s) is no longer functional and cannot be repaired

Change in condition: A change in condition makes the existing unit(s) inadequate for the hearing-related activities of daily living and improvement is expected with replacement

Processor age: Current sound processor is at least five years old>=5 years

Not Medically Necessary

Convenience/early upgrade: Replacement or upgrade of a properly functioning BAHA or its external components is considered not medically necessary when requested only for convenience or to upgrade to newer technology before the timeframe noted in replacement criteria

Requests to replace or upgrade a properly functioning bone-anchored hearing aid (BAHA) solely for member convenience or to obtain newer technology before the timeframes specified in the replacement criteria are excluded from medical necessity coverage. The policy states that replacement or upgrade for this reason "is considered not medically necessary when requested only for convenience or to simply upgrade to a newer technology before the timeframe noted in section II."

Replacement or upgrade of an existing, properly functioning BAHA and/or its external components (external sound processor) is not medically necessary when the request is made only for convenience or solely to obtain newer technology prior to the replacement timeframes in section II (for example, before the current sound processor reaches 5 years of age). The policy explicitly states such requests may be denied as they do not meet the coverage criteria.

Procedure and Billing Codes; Audiometric Thresholds

Procedure CPT CodesCPT

69710	Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone.
69711	Removal or repair of electromagnetic bone conduction hearing device in temporal bone.
69714	Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69716	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69717	Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69719	Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69726	Removal, entire osseointegrated implant, skull; with percutaneous attachment to external speech processor.
69727	Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex.
69728	Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex.
69729	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex.

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HCPCS CodesHCPCS

L8690	Auditory osseointegrated device, includes all internal and external components.
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each.
L8692	Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment.
L8693	Auditory osseointegrated device abutment, any length, replacement only.
L8694	Auditory osseointegrated device, transducer/actuator, replacement only, each.

inv-08: Pure tone average bone conduction threshold 6 measured at 0.5,1,2,3 kHz; must be consistent with FDA indications for the requested device

Measurement frequenciesPure tone average bone conduction threshold measured at 0.5, 1, 2, and 3 kHz

Requirement linkageThreshold must be consistent with the FDA indications for the requested device

ContextThis audiometric requirement is part of initial implantation/headband coverage criteria for BAHA

inv-09: Unaided speech discrimination score (SDS) 6 30%

Measurement contextSDS is required as part of initial BAHA coverage audiometry

Documentation note

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for surgical implantation, removal, replacement, and for billing of auditory osseointegrated devices and related procedures. Providers must obtain prior authorization before scheduling or performing BAHA implantation, explantation, replacement procedures, or when submitting claims for devices (including codes such as CPT 69710–69730 and HCPCS L8690–L8694).

Affected CPT: 69710, 69711, 69714, 69716, 69717, 69719, 69726–69730
Affected HCPCS: L8690, L8691, L8692, L8693, L8694

Denial Risk

Replacement / Upgrade Denial Risk

Replacement or upgrade requests for a properly functioning BAHA or external sound processor requested solely for convenience or to obtain newer technology may be denied. Replacements are considered medically necessary only when the device is nonfunctional and cannot be repaired, when the member’s condition has changed such that the existing device is inadequate for activities of daily living and improvement is expected with replacement, or when the current sound processor is at least five years old.

Clinical Background

Bone-anchored hearing aids (BAHAs) transmit sound via bone conduction and are used when conventional air-conduction hearing aids are ineffective or not tolerated (for example, canal atresia, chronic infections, or allergic reactions). Implantable BAHA systems include an osseointegrated implant and external sound processor and are generally preferred over non-implant headband devices for older children and adults because of improved tolerability and sound quality. Implantable devices are typically feasible once the patient has sufficient skull bone thickness (commonly around age six), while headband or non-implantable options are an interim choice for younger children or when implantation is not medically appropriate.

Key Definitions and Components

inv-17: Unilateral sensorineural hearing loss (single-sided deafness) 6 definition and indication for BAHA

DefinitionProfound sensorineural hearing loss in one ear with normal hearing in the contralateral ear

Indication for BAHABAHA may be indicated when conventional air-conduction hearing aids cannot restore hearing

Clinical contextUsed to achieve improved auditory acuity by transmitting sound through bone into the inner ear

inv-18: BAHA components 6 implanted osseointegrated implant and abutment, external sound processor, transducer/actuator; HCPCS L8690-L8694 referenced

Primary componentsImplanted osseointegrated implant and abutment

External componentsExternal sound processor (body-worn or headband for non-implant use)