CurrentMaryland Medicaid (Maryland Department of Health)Policy N/A

Clinical Coverage Criteria: Hearing Aids, Cochlear Implants, and Bone‑Anchored Hearing Aids

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Clinical coverage criteria for Maryland Medicaid for hearing aids, cochlear implants, and bone-anchored hearing aids (BAHA) describing medical necessity criteria for pediatric and adult participants.

Policy Summary

PayerMaryland Medicaid (Maryland Department of Health)

PolicyClinical Coverage Criteria: Hearing Aids, Cochlear Implants, and BAHA

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain written medical clearance from a physician (exam within the prior 6 months) and document audiologist recommendation and fitting for initial devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤21pediatric age cutoff

≥21adult age threshold

25 dBpediatric PTA

40 dBadult unilateral PTA

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CurrentMaryland Medicaid (Maryland Department of Health)Policy N/A

Clinical Coverage Criteria: Hearing Aids, Cochlear Implants, and Bone‑Anchored Hearing Aids

Customize your policy alerts

Sign up for all Maryland Medicaid (Maryland Department of Health) policy alerts

Know when Maryland Medicaid (Maryland Department of Health) releases new policies or updates existing guidance.

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Clinical coverage criteria for Maryland Medicaid for hearing aids, cochlear implants, and bone-anchored hearing aids (BAHA) describing medical necessity criteria for pediatric and adult participants.

Policy Summary

PayerMaryland Medicaid (Maryland Department of Health)

PolicyClinical Coverage Criteria: Hearing Aids, Cochlear Implants, and BAHA

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain written medical clearance from a physician (exam within the prior 6 months) and document audiologist recommendation and fitting for initial devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤21pediatric age cutoff

≥21adult age threshold

25 dBpediatric PTA

40 dBadult unilateral PTA

Coverage Criteria for Auditory Devices

Hearing aid coverage for children (<=21 years)

Covered when ALL of the following are met

Pediatric hearing aid criteria: Participant has a hearing loss of 25 dB or greater; AND hearing aid(s) recommended and fitted by an audiologist; AND for initial hearing aid(s), written medical clearance obtained from a physician who has performed a medical examination within the past 6 months.25 dB

Applies to unilateral or bilateral hearing aids for participants up to age 21.

Hearing aid coverage for adults (>=21 years)

Unilateral covered when ALL of the following are met

Adult unilateral hearing aid: Participant has a pure tone average threshold of 40 dB or greater at 500, 1000, 2000 and 3000 Hz in the better ear; AND documentation that patient is alert and able to utilize their aid appropriately; AND hearing aid is recommended and fitted by an audiologist; AND for initial hearing aid, written medical clearance from a physician who has performed a medical examination within the past 6 months.40 dB

Applies to unilateral hearing aids for participants 21 years and older.

Bilateral hearing aids for adults (additional criteria)

Bilateral covered when the unilateral criteria are met AND ANY of the following

Bilateral hearing aid additional criteria: Participant has visual impairment meeting the definition of statutory blindness; OR participant is a previous successful bilateral hearing aid user with meaningful objective benefit documented; OR participant demonstrates significant hearing-related disability in educational, vocational, or community settings with a unilateral aid and meaningful objective benefit from bilateral aids can be documented.

Requires documentation of benefit or qualifying visual impairment.

Cochlear implantation in children (9 months - 20 years)

Covered when ALL of the following are met

Pediatric cochlear implant candidacy: Bilateral severe to profound pre- or post-lingual sensorineural hearing loss defined as a pure tone average threshold of 70 dB or greater at 500, 1000, and 2000 Hz; AND a minimum 3 to 6 month trial with appropriate binaural hearing aids has occurred if child over the age of three is not previously experienced with hearing aids (radiologic evidence of cochlear ossification may justify a shorter trial); AND limited or no benefit from appropriate binaural hearing aids documented by lack of progress in auditory skills (e.g., MAIS/ESP) in younger children or <30% correct on MLNT/LNT in older children; AND documentation that the child and parent/guardian are willing and able to participate in a post-cochlear implant rehabilitation program; AND freedom from middle ear infection, an accessible cochlear lumen structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic central nervous system areas; AND no contraindications to surgery.70 dB

Applies to children age 9 months to 20 years.

Cochlear implantation in adults (>=21 years)

Unilateral cochlear implant covered when ALL of the following are met

Adult cochlear implant candidacy: Bilateral severe to profound pre- or post-lingual sensorineural hearing loss defined as a pure tone average threshold of 70 dB or greater at 500, 1000, and 2000 Hz; AND limited benefit from appropriate hearing aids defined as scoring 50% or less in best-aided listening condition on a test of open-set sentence recognition (e.g., HINT); AND the participant is willing and able to participate in a post-cochlear implant rehabilitation program; AND freedom from middle ear infection, an accessible cochlear lumen structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic central nervous system areas; AND no contraindications to surgery.70 dB; <=50% sentence recognition

Applies to participants 21 years and older. Bilateral implants require meeting unilateral criteria plus either previous successful bilateral CI use or determination that unilateral CI plus contralateral HA is inadequate.

Bone-anchored hearing aids (BAHA) coverage

Covered when ALL of the following are met

BAHA candidacy: Participant is age ≥5 years for implant (softband or nonimplantable devices may be used <5 years as clinically indicated); AND unilateral implant: conductive or mixed hearing loss with a pure tone average bone conduction threshold at 500, 1000, 2000, and 3000 Hz that meets device-specific limits (≤45 dB, 55 dB, or 65 dB depending on device model); AND bilateral implants: moderate-to-severe bilateral symmetric conductive or mixed hearing loss meeting the above bone conduction thresholds with symmetric bone conduction defined per device-specific interaural difference criteria; AND participant has a medical condition preventing use of a conventional air conduction hearing aid (e.g., atresia, severe chronic otitis media/externa, tumors of the external ear canal or tympanic cavity, dermatitis/hypersensitivity to ear molds, or other anatomic/medical contraindications).Device-specific bone conduction PTA thresholds as listed

Single-sided deafness (normal contralateral hearing PTA <20 dB) is also covered for participants ≥5 years.

No explicit exclusions are listed beyond failure to meet device‑specific audiometric thresholds or medical suitability criteria. Standard surgical contraindications and medical unsuitability (for example, active middle ear infection or anatomical features that preclude implantation) apply for implantable devices. For BAHA, exclusion from coverage would occur when the participant does not meet the device‑specific bone conduction PTA thresholds or lacks a medical condition that prevents use of conventional air conduction hearing aids.

Devices are considered not medically necessary when the stated audiometric thresholds, documentation requirements, trial requirements, or anatomical/medical suitability criteria are not met. Examples include: lack of documented hearing loss meeting the pediatric threshold of ≥25 dB for participants ≤21 years, absence of a pure tone average ≥40 dB in the better ear for adult unilateral hearing aid candidacy, failure to demonstrate limited or no benefit from appropriate hearing aids or to complete required amplification trials before cochlear implantation, missing audiologist recommendation/fitting, or absence of required written medical clearance from a physician based on an exam within the prior 6 months. For BAHA, devices are not medically necessary when the participant does not meet the specified bone conduction PTA limits for the device model or does not have a qualifying anatomic/medical indication for implantable bone conduction devices.

Coding and Threshold Key Values

No codes listedmixed

No codes listed

Pediatric hearing loss threshold — key facts

Age rangeParticipants up to age 21 years

Threshold>= 25 dB (hearing loss)

RequirementHearing aid(s) recommended and fitted by an audiologist

Initial device requirementWritten medical clearance from physician who performed exam within past 6 months for initial hearing aid(s)

Adult unilateral hearing aid PTA — key facts

Applicable ageParticipants 21 years of age and older

PTA threshold (better ear)

Provider Requirements and Documentation

Prior Authorization

Medical clearance and audiology fitting required

Initial hearing aids and cochlear implant–related amplification require both (1) written medical clearance from a physician who performed a medical examination within the past 6 months and (2) that the hearing aid(s) be recommended and fitted by an audiologist.

Written medical clearance must be from a physician who has performed a medical exam within the past 6 months (required for initial devices).
Hearing aids must be recommended and fitted by an audiologist; audiologist recommendation and fitting must be documented.

Step Therapy

Amplification trial required before cochlear implantation

Cochlear implant candidates older than 3 years must have a documented trial of appropriate binaural hearing aids for a minimum of 3 to 6 months unless the child was previously experienced with hearing aids or radiologic cochlear ossification justifies a shorter trial.

Minimum 3–6 month trial with appropriate binaural hearing aids for children >3 years who are not previously experienced with hearing aids.

Background

Hearing aids, cochlear implants, and bone‑anchored hearing aids (BAHA) are interventions used to manage conductive, mixed, and sensorineural hearing loss. Device selection depends on degree of hearing loss and pure tone average thresholds (for example, pediatric hearing aid candidacy is ≥25 dB, adult unilateral hearing aid candidacy is ≥40 dB PTA, and cochlear implant candidacy is generally ≥70 dB PTA at key frequencies), prior benefit from amplification, anatomical suitability for implantation, and the participant’s ability to participate in post‑implant rehabilitation. BAHA devices are indicated when conventional air conduction hearing aids cannot be used due to anatomic or medical reasons (e.g., atresia, chronic otitis externa/media, tumors, dermatitis or hypersensitivity to ear molds) and when device‑specific bone conduction thresholds are met; softband or nonimplantable options may be used for children under age five as clinically indicated.

Key Definitions and Thresholds

Severe to profound sensorineural hearing loss — cochlear implant candidacy threshold

DefinitionSevere to profound sensorineural hearing loss defined as PTA >= 70 dB at 500, 1000, and 2000 Hz

ApplicabilityUsed to determine cochlear implant candidacy for children and adults as specified in implant criteria

Associated requirementsMust also meet limited-benefit and rehabilitation participation criteria as outlined for cochlear implantation

Adult unilateral hearing aid candidacy — PTA threshold

PTA threshold>= 40 dB pure tone average at 500, 1000, 2000, and 3000 Hz in the better ear

Age applicabilityApplies to unilateral hearing aid candidacy for participants 21 years and older