CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria — Hearing Aids (Excludes Implantable Devices)

Clinical review criteria governing medical necessity, coverage, and coding for prescription hearing aids (excluding implantable devices) for Kaiser Foundation Health Plan of Washington members and their providers.

Policy Summary

PayerKaiser Permanente

PolicyHearing Aids (Excludes Implantable Devices) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify authorization requirements by plan type using the Pre-authorization Code Check and document examination by a licensed MD/DO or certified audiologist before dispensing hearing aids.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥30 dB HLAdult audiometric criterion

ENT evaluationPediatric requirement

HB 1222WA law

OTC devicesNon-covered

92629, V5030Representative codes

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Coverage & Medical Necessity Criteria

Medical necessity criteria

Prescription hearing aids may be considered medically necessary when ALL of the following are met (distinct adult and pediatric rules):

Adult candidacy: Patient is age 19 years or older AND has hearing thresholds 30 dB HL or greater at two or more of the following frequencies: 500, 1000, 2000, 3000, or 4000 Hz.Hearing thresholds ≥30 dB HL at ≥2 specified frequencies

For non‑Medicare members; review member rider/contract for variations

Pediatric candidacy: Patient is under 18 years old AND has been evaluated by an otolaryngologist AND hearing aids have been prescribed by an audiologist or otolaryngologist.age <18

Pediatric evaluation and prescription required

Provider examination requirement: Member must be examined by a licensed physician (MD or DO) or an audiologist (CCC‑A or CCC‑MSPA) before obtaining hearing aids.

Required per Services Benefit

Prescription, dispensing, and follow‑up: Hearing aids must be purchased and prescribed as a result of the required exam. Benefits include the hearing aid instruments, initial batteries and necessary ancillary equipment obtained with purchase, manufacturer warranty when provided, rental while primary unit is repaired, repairs/servicing/alteration, and a follow‑up consultation within 30 days after delivery with the prescribing physician or audiologist.30 days

Services Benefit provisions

Over-the-counter (OTC) hearing assistive listening devices / personal sound amplification products (PSAPs), wireless hearing aid accessories, consumer "hearables," and ear buds or headphones are not covered under the hearing services benefit and will be denied if submitted as hearing aids. Examples explicitly listed include Pocketalker®, TV Ears®, Eargo, BeHear, Cyberscience Amplifier, NewEar™, and similar non-prescription devices. Ancillary items such as batteries or accessories are only covered when provided as part of the purchase of a prescribed hearing aid; standalone batteries or accessories obtained separately are not covered.

Non-implantable intraoral bone conduction hearing aids (for example, the SoundBite™ Hearing System) are considered investigational and not covered under this policy.

For Medicare members, Kaiser follows Medicare coverage guidance. The CMS Medicare Benefit Policy Manual (chapter 16, section on Hearing Aids and Auditory Implants) and applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) govern coverage for Medicare enrollees; in the absence of an active NCD or LCD, Kaiser uses its own Clinical Review Criteria but continues to defer to Medicare policy for medical necessity determinations.

CPT/HCPCS Codes and Audiometric Thresholds

Covered CPT codes (evaluation/selection/fitting) - additional post-fittingCPTCovered

92637

Hearing aid post-fitting follow-up services; each additional 15 minutes

Covered CPT codes (evaluation/selection/fitting) - fitting/assistiveCPTCovered

No codes listed

Covered HCPCS/V codes (hearing aid devices and accessories)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
V5100	Hearing aid, bilateral, body worn
V5120	Binaural, body
V5130	Binaural, in the ear
V5140	Binaural, behind the ear
V5171	Hearing aid, contralateral routing device, monaural, in the ear (ITE)
V5172	Hearing aid, contralateral routing device, monaural, in the canal (ITC)

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1/5

inv-07: Adult audiometric threshold — Hearing thresholds 30 dB HL or greater at two or more of 500, 1000, 2000, 3000, or 4000 Hz.

Adult audiometric thresholdHearing thresholds 30 dB HL or greater at two or more of the following frequencies: 500, 1000, 2000, 3000, or 4000 Hz.

Age requirementApplies to adult patients age 19 years or older.

Frequency countCriterion requires thresholds ≥30 dB HL at TWO or more specified frequencies.

Applicability noteCriteria apply to non‑Medicare members; review member rider/contract for variations that may supersede clinical criteria.

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Pre-authorization check required

Verify authorization requirements by plan type before providing services. Use the Pre-authorization Code Check to confirm whether prior authorization is required for specific CPT/HCPCS codes.

Use Pre-authorization Code Check for plan-specific authorization requirements
Authorization may vary by member rider/contract; review member contract prior to coverage determination

Documentation Required

Required clinical exam and dispensing documentation

Provider must document that the member was examined by a licensed physician (MD or DO) or an audiologist (CCC-A or CCC-MSPA) prior to obtaining hearing aids. Maintain documentation of the examination, prescription, dispensing notes, and a follow-up consultation within 30 days of delivery when applicable.

Documented exam by MD/DO or audiologist (CCC-A or CCC-MSPA) prior to dispensing
For adults: audiometric thresholds demonstrating hearing loss per policy criteria must be included
For pediatric patients: documentation of evaluation by an otolaryngologist is required
Include prescription, device selection rationale, fitting and programming notes, and follow-up visit within 30 days

Documentation Required

Additional documentation for implants/alternate devices

If requesting related implantable devices (eg, cochlear implant, BAHA) or non-standard alternate devices, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Attach last 6 months of clinical notes from requesting provider/specialist when submitting implant/alternate device requests
Refer to the separate criteria documents for Cochlear Implant and Bone Anchored Hearing System (BAHA)

Denial Risk

Failure to meet medical necessity criteria

If medical necessity criteria are not met, the request may be denied. Examples include inadequate audiometric thresholds for adults or missing required ENT evaluation for pediatric patients.

Adult denial risk: audiometric thresholds do not meet required hearing loss criteria (eg, thresholds <30 dB HL at the specified frequencies)
Pediatric denial risk: absence of otolaryngologist evaluation when required
Incomplete documentation (exam, prescription, fitting, follow-up) may result in denial

Note

Non-covered OTC devices

Over-the-counter hearing assistive listening devices (PSAPs/ALDs), wireless hearing aid accessories, hearables, and earbuds/headphones are not covered under the hearing hardware benefit.

Examples of non-covered OTC devices: Cyberscience Amplifier, NewEar™, Eargo, BeHear, Magic Ear, Pocketalker®, TV Ears®, earbuds/headphones
Batteries or ancillary equipment obtained other than at initial purchase are not covered

Background & Context

Traditional prescription hearing aids are externally worn amplification devices that collect sound with an external microphone and deliver amplified sound to the ear canal via an ear mold or earmold-fitting. Selection and provision of hearing aids require a complete audiologic work-up performed by a qualified clinician and a prescription based on the member’s hearing needs. Under the plan benefit, members must be examined by a licensed physician (MD or DO) or a certified audiologist prior to obtaining hearing aids, and benefits include the hearing instruments, initial batteries and necessary ancillary equipment provided with purchase, warranty when offered, rental while the primary unit is repaired, repairs/servicing, and a follow-up consultation within 30 days of delivery.

OpenPayer

Clinical Review Criteria — Hearing Aids (Excludes Implantable Devices)

Coverage & Medical Necessity Criteria

CPT/HCPCS Codes and Audiometric Thresholds

Authorization, Documentation, and Provider Responsibilities

Background & Context

Key Definitions