Audiology Services and Devices (Hearing Aids, Cochlear Implants, Auditory Osseointegrated Devices)
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Defines medical necessity, coverage, limitations, and clinical criteria for audiology assessments and devices (hearing aids, cochlear implants, bone-anchored/auditory osseointegrated devices) for Maryland Physicians Care members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Audiology Services and Devices
General covered services
MPC considers the following audiology services and devices medically necessary when criteria are met
See detailed device-specific criteria
Hearing aid coverage in children (<=21 years)
Covered when ALL of the following are met
Children hearing aids
- Participant age up to 21 yearsage <=21
- Hearing loss of 25 dB or greaterPTA >=25 dB
- Hearing aid(s) recommended and fitted by an audiologist
- For initial hearing aid(s), written medical clearance obtained from a physician who performed a medical exam within the past 6 months
Hearing aid coverage in adults (>=21 years)
Unilateral hearing aids covered when ALL criteria met; bilateral when additional conditions met
Unilateral adult hearing aid
- Participant age >=21 yearsage >=21
- Pure tone average threshold >=40 dB at 500, 1000, 2000 and 3000 Hz in the better earPTA >=40 dB
- Documentation that patient is alert and able to utilize their aid appropriately
- Hearing aid recommended and fitted by an audiologist
- For initial hearing aid, written medical clearance from a physician who performed medical exam within past 6 months
Bilateral adult hearing aid additional criteria
- Participant has visual impairment meeting definition of statutory blindness
Must also meet unilateral criteria
- Previous successful bilateral hearing aid user with meaningful objective benefit documented over unilateral amplification
Must also meet unilateral criteria
- 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
Must also meet unilateral criteria
Cochlear implantation in children (9 months - 20 years)
Covered when ALL of the following are met
Pediatric cochlear implant
- Age 9 months to 20 years9 months <= age <=20 years
- Bilateral severe to profound pre- or post-lingual sensorineural hearing loss defined as pure tone average >=70 dB at 500, 1000, and 2000 HzPTA >=70 dB
- Minimum 3–6 month trial with appropriate binaural hearing aids if child over age 3 and not previously experienced with hearing aids (radiologic evidence of cochlear ossification may justify shorter trial)trial 3-6 months
- Limited or no benefit from appropriate binaural hearing aids defined by age-specific measures (younger: lack of progress in auditory skills on measures such as MAIS or ESP over 3–6 months; older: <30% correct on MLNT/LNT)<30% on MLNT/LNT for older children
- Child and parent/guardian willing and able to participate in post-implant rehabilitation
- Freedom from middle ear infection, accessible cochlear lumen suitable for implantation, freedom from lesions of auditory nerve/CNS, and no contraindications to surgery
Cochlear implantation in adults (>=21 years)
Unilateral cochlear implant covered when ALL criteria met; bilateral when additional conditions met
Unilateral adult cochlear implant
- Participant age >=21 yearsage >=21
- Bilateral severe to profound pre- or post-lingual sensorineural hearing loss defined as pure tone average >=70 dB at 500, 1000, and 2000 HzPTA >=70 dB
- Limited benefit from appropriate hearing aids defined as <=50% best-aided score on open-set sentence recognition test (e.g., HINT)<=50%
- Willing and able to participate in post-implant rehabilitation program
- Freedom from middle ear infection, accessible cochlear lumen suitable for implantation, freedom from lesions of auditory nerve/CNS, and no contraindications to surgery
Bilateral adult cochlear implant additional criteria
- Participant is a previous successful bilateral cochlear implant user
Must meet unilateral implant criteria first
- It has been determined that a unilateral cochlear implant plus a hearing aid in the contralateral ear will not result in adequate amplification
Must meet unilateral implant criteria first
Bone-anchored hearing aids (BAHA) / auditory osseointegrated devices
Covered when ALL of the following are met
BAHA candidacy
- Age >=5 years for implantable BAHA; non-implantable or soft-band devices for <5 years or as clinically indicatedage criteria
- For unilateral implant: conductive or mixed hearing loss with pure tone average bone conduction threshold at 500, 1000, 2000, and 3000 Hz <=45, 55, or 65 dB depending on device model as listed in policydevice-specific BC thresholds
- For bilateral implants: moderate-to-severe bilateral symmetric conductive or mixed hearing loss meeting device bone conduction thresholds in both ears; symmetry defined per device as <10 dB average difference between ears (or <15 dB at individual frequencies) as specifiedsymmetry criteria
- Has medical condition preventing use of conventional air conduction hearing aid (e.g., congenital or surgically induced external/middle ear malformations, severe chronic external otitis or otitis media, tumors of external ear canal, dermatitis or hypersensitivity to molds, or other anatomic/medical contraindications)
The following services are not covered by Maryland Physicians Care when they are not medically necessary or otherwise excluded by this policy: hearing aids and accessories not medically necessary; cochlear implant services and external components not medically necessary; cochlear implant audiology services and external components provided less than 90 days after the surgery or already covered through initial implant/surgery reimbursement; spare or backup cochlear implant or auditory osseointegrated device components; spare or backup hearing aids, equipment, or supplies; repairs to spare or backup devices or components; investigational or experimental services or devices; additional professional fees/overhead for a new hearing aid when a dispensing fee claim has been made to MPC; and loaner hearing aids.
Replacements are considered not medically necessary when the existing device or component is functional, repairable, and appropriately corrects or ameliorates the member’s problem or condition. This includes replacement of hearing aids, equipment, cochlear implant components, and auditory osseointegrated device components if the current devices remain serviceable and repairable. Limits on replacement supplies also apply (for example, earmold frequency and cochlear implant accessory limits listed elsewhere in the policy).
Coding, Thresholds, and Measurement Criteria
| No codes listed |
Authorization, Trials, and Documentation Requirements
Obtain MCO preauthorization and meet 6‑month initiation window
Preauthorization for audiology services and devices may be required by the member's MCO. Any services authorized must be rendered or initiated within 6 months from the date the authorization was issued.
Complete and document required hearing‑aid trial prior to cochlear implant
Before cochlear implantation, document an appropriate hearing‑aid trial. For children older than 3 who are not previously experienced with hearing aids, a minimum 3–6 month trial with appropriate binaural hearing aids is required; for adults, document a hearing‑aid trial demonstrating limited benefit from appropriate hearing aids (see adult implant criteria).
- Children >3: minimum 3–6 month trial with appropriate binaural hearing aids unless justified (e.g., cochlear ossification).
- Adults: document limited benefit (see <=50% best‑aided open‑set sentence recognition threshold) from appropriate hearing aids prior to implantation.
Provide complete clinical justification with request
Submit clinical documentation that justifies how the member meets the medical necessity criteria for the requested device or service. Follow the clinical coverage criteria and the MDH/MPC provider manual for required documentation elements.
- Include testing results and measures referenced in coverage criteria (e.g., PTA, open‑set sentence recognition, age‑specific speech tests).
- Include physician medical clearance when required (e.g., for initial hearing aid within past 6 months).
Confirm MCO referral/preauthorization and schedule within authorization period
Verify whether the member must obtain a preauthorization or referral from their MCO before audiology evaluation or treatment; ensure any authorized services are started within 6 months of the authorization date to avoid denial.
- Confirm MCO referral/preauthorization requirements before scheduling audiologist visits.
- Schedule services so they are rendered or initiated within the 6‑month authorization validity period.
Background and Scope
Audiology services for Medicaid's EPSDT population are provided through the member’s MCO effective July 1, 2018. This policy adopts Maryland Department of Health regulations and defines medical necessity, coverage, limitations, and clinical criteria for audiology assessments and devices, including hearing aids, cochlear implants, and auditory osseointegrated devices. Coverage requires that services and devices meet the policy’s specific clinical criteria and documentation requirements and that any required MCO prior authorization or initiation timelines be followed.
Definitions
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