CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1421.DC

Hearing Aid Coverage

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Defines medical necessity criteria, limitations, and documentation requirements for authorization of hearing aids and related devices for MedStar Family Choice District of Columbia enrollees.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyHearing Aid Coverage

Policy CodePolicy 1421.DC

Change TypeMaterial and clarifying updates (device criteria, BAHA, exclusions, administrative)

Effective DateOct 1, 2020

Last ReviewJul 25, 2025

Next Review DateJul 23, 2024

Key ActionSubmit audiologist evaluation including audiogram and, for initial hearing aids, include written physician medical clearance from an exam within the prior 6 months.

SourceLink

POLICY UPDATE CHANGES

Added criteria for coverage of non-implantable or soft band devices for enrollees less than 5 years of age.

Clarified criteria for Auditory Osseointegrated Devices or Bone Integrated Hearing Aids (BAHA).

Broadened indications for bilateral hearing aids for adults by removing the 'child under 21' reference and adding 'community' to settings demonstrating hearing-related disability.

Exclusions and limitations were clarified.

Updated Responsible Parties titles in administrative sections.

25children threshold (dB HL)

40adult PTA threshold (dB HL)

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CurrentmedstarfamilychoicedistrictofcolumbiaPolicy 1421.DC

Hearing Aid Coverage

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Sign up for medstarfamilychoicedistrictofcolumbia Policy 1421.DC alerts

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Defines medical necessity criteria, limitations, and documentation requirements for authorization of hearing aids and related devices for MedStar Family Choice District of Columbia enrollees.

Policy Summary

Payermedstarfamilychoicedistrictofcolumbia

PolicyHearing Aid Coverage

Policy CodePolicy 1421.DC

Change TypeMaterial and clarifying updates (device criteria, BAHA, exclusions, administrative)

Effective DateOct 1, 2020

Last ReviewJul 25, 2025

Next Review DateJul 23, 2024

Key ActionSubmit audiologist evaluation including audiogram and, for initial hearing aids, include written physician medical clearance from an exam within the prior 6 months.

SourceLink

POLICY UPDATE CHANGES

Added criteria for coverage of non-implantable or soft band devices for enrollees less than 5 years of age.

Clarified criteria for Auditory Osseointegrated Devices or Bone Integrated Hearing Aids (BAHA).

Broadened indications for bilateral hearing aids for adults by removing the 'child under 21' reference and adding 'community' to settings demonstrating hearing-related disability.

Exclusions and limitations were clarified.

Updated Responsible Parties titles in administrative sections.

25children threshold (dB HL)

40adult PTA threshold (dB HL)

Coverage Criteria for Hearing Aids and Related Devices

inv-01: Children under 21 — Hearing Aids — Covered when ALL of the following are met

Covered when ALL of the following are met

Children hearing aid criteria: i. The participant has a hearing loss of 25 dB HL or greater; and ii. Hearing aid(s) recommended and fitted by an audiologist; and iii. For initial hearing aid(s), written medical clearance is obtained from a physician who has performed a medical examination within the past 6 months.25 dB HL

Applies to unilateral or bilateral hearing aids for enrollees under 21.

inv-02: Adults 21 and older — Unilateral Hearing Aid — Covered when ALL of the following are met

Covered when ALL of the following are met

Adult unilateral hearing aid criteria: i. The participant has a pure tone average threshold of 40 dB HL or greater at 500, 1,000, 2,000 and 3,000 Hz in the better ear; and ii. Documentation that patient is alert and able to utilize their aid appropriately; and iii. Hearing aid is recommended and fitted by an audiologist; and iv. For initial hearing aid, written medical clearance from a physician who has performed a medical examination within the past 6 months.40 dB HL

Sets authorization for unilateral amplification in adults age 21 and older.

inv-03: Adults 21 and older — Bilateral Hearing Aids — Covered when ALL of the following are met

Covered when ALL of the following are met

Adult bilateral hearing aid criteria: Meets unilateral hearing aid criteria for adults 21 and older; and ONE of: i. The participant has visual impairment meeting the definition of statutory blindness; or ii. The participant is a previous successful bilateral hearing aid user and meaningful objective benefit to the participant over unilateral amplification can be documented; or iii. The 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.

Bilateral coverage requires additional documentation of benefit or disability; statutory blindness defined per Social Security Act.

inv-04: Auditory Osseointegrated Devices / BAHA — Covered when ALL of the following are met

Covered when ALL of the following are met

BAHA candidacy and device thresholds: i. Enrollee is 5 years of age or older for implantable devices (non‑implantable or soft band devices for participants less than 5 years of age are covered); and ii. Unilateral implant candidacy: conductive or mixed hearing loss with a pure tone average bone conduction threshold at 500, 1000, 2000, and 3000 Hz that is less than or equal to device‑specific limits (e.g., ≤45 dB, ≤55 dB, or ≤65 dB depending on device model); and iii. Bilateral implant candidacy: moderate‑to‑severe bilateral symmetric conductive or mixed hearing loss meeting the above bone conduction thresholds in both ears with symmetry defined as ≤10 dB average interaural difference (or device‑specific frequency criteria) or ≤15 dB at individual frequencies as specified for device models; and iv. The enrollee has a medical condition preventing use of a conventional air conduction hearing aid (for example: congenital atresia, chronic middle/outer ear infection exacerbated by standard aids, allergic reactions to standard aids, single‑sided deafness, tumors of the external ear canal/tympanic cavity).device‑specific bone conduction limits

Coverage includes soft‑band/nonimplantable devices for children under 5; device thresholds vary by model as specified.

Replacement of hearing aids is not authorized when the enrollee's existing devices are functional, repairable, and appropriately correct or ameliorate the problem or condition. Improperly fitted earmolds will not be routinely replaced unless the replacement is performed by a different provider and the replacement service has not been previously claimed. Additional professional fees or overhead charges associated with a new hearing aid are excluded when a dispensing fee has already been claimed. Loaner hearing aids, hearing aids that are not FDA approved, devices not listed on the District of Columbia Medicaid Fee Schedule, and audiology services not on the Fee Schedule are also excluded.

Use of hearing aids for conditions other than documented hearing loss (for example, tinnitus) is not considered medically necessary for authorization of hearing aids and is excluded from coverage.

inv-07: Hearing thresholds for device eligibility — children/adult PTA and BAHA thresholds summarized

Children (<21) hearing-aid thresholdHearing loss of 25 dB HL or greater (authorization requires audiologist recommendation and, for initial aids, physician medical clearance within prior 6 months)

Adults (≥21) unilateral PTA thresholdPure tone average (PTA) ≥40 dB HL at 500, 1000, 2000 and 3000 Hz in the better ear

BAHA (osseointegrated) unilateral bone-conduction limitsBone conduction PTA ≤ device-specific limits: ≤45 dB, ≤55 dB, or ≤65 dB depending on device model (specified models listed in policy)

BAHA bilateral symmetry requirementSymmetric bone conduction defined as ≤10 dB average interaural difference (device-specific frequency criteria apply); or ≤15 dB at individual frequencies for specified devices

Coding and Device Eligibility

inv-07: Hearing thresholds for device eligibility — children/adult PTA and BAHA thresholds summarized

Child hearing-aid threshold25 dB HL or greater for unilateral or bilateral hearing aids for enrollees under 21 (requires audiologist fitting and, for initial aids, physician exam within 6 months)

Adult unilateral hearing-aid PTAPTA ≥40 dB HL at 500, 1000, 2000 and 3000 Hz in the better ear (also requires alertness/ability to use aid, audiologist fitting, and physician medical clearance for initial aids)

BAHA candidacy ageImplantable BAHA devices: patient ≥5 years; nonimplantable/soft-band devices allowed for <5 years

BAHA unilateral bone-conduction thresholdsBone conduction PTA at 500,1000,2000,3000 Hz ≤45, 55, or 65 dB depending on device model

Provider Actions, Authorization, and Documentation Requirements

Prior Authorization

Prior authorization and medical exception review

Hearing aids are authorized when the policy’s medical necessity criteria are met. If a request does not specifically meet the listed criteria, submit supporting medical records or literature for review; such requests will be reviewed by a Medical Director for a medical exception.

Submit complete documentation showing the applicable coverage criteria are met for the enrollee’s age group and device type.
If criteria are not met, include supporting clinical records or literature for Medical Director review.

Step Therapy

Device selection determined by clinical criteria (not step therapy)

Device selection is governed by the clinical criteria and the enrollee’s anatomy/medical contraindications rather than a step-wise therapy requirement. Choose conventional air-conduction hearing aids or consider osseointegrated/BAHA devices when indicated by anatomy or medical contraindications (e.g., congenital atresia, chronic infections, allergic reactions, single-sided deafness, tumors, or other anatomic/medical conditions).

Background

Hearing loss may be sensorineural, conductive, or mixed. Hearing aids are the primary rehabilitative option for most hearing impairments and are appropriate for children and motivated adults whose hearing loss interferes with educational, vocational, or social functioning. Degree of hearing loss is commonly described using decibel hearing level (dB HL) categories and by the Pure Tone Average (PTA), the average of threshold levels across specified frequencies; PTA and dB HL thresholds are used in this policy to determine medical necessity for amplification.

Definitions and Clinical Thresholds

inv-13: Degree of hearing loss (dB HL) — Clark classification: Normal to Profound ranges

Normal–10 to 15 dB HL

Slight16 to 25 dB HL

Mild26 to 40 dB HL

Moderate41 to 55 dB HL

Moderately severe56 to 70 dB HL

Severe71 to 90 dB HL

Profound91+ dB HL

Revision History and Policy Changes

2024-07-24revisionLatest

Broadened indications for bilateral hearing aids for adults (removed child reference and added 'community'), clarified BAHA criteria, and added coverage criteria for non-implantable/soft-band devices for children under 5; exclusions and limitations clarified.

2020-10-01effective_date

Policy effective date established.

2020-07-22administrative_update