CurrentMedStar Family Choice MarylandPolicy 1421

Hearing Aid Coverage

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 1421 alerts

Get alerted when Policy 1421 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs medical-necessity coverage and authorization of hearing aids, auditory osseointegrated or bone-anchored hearing devices, and related audiology services for MedStar Family Choice Maryland members with hearing loss. It establishes age-specific clinical criteria, documentation requirements, acceptable devices and services, and exclusions.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyHearing Aid Coverage

Policy CodePolicy 1421

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit an audiologist evaluation, including an audiogram, for hearing-aid review.

SourceLink

POLICY UPDATE CHANGES

Updated criteria for auditory osseointegrated devices and bone-anchored hearing aids.

Added a six-month examination and medical-clearance requirement for the applicable BAHA criterion.

Under 21Children may qualify for hearing aids

40 dB HLAdult unilateral PTA threshold

5 yearsMinimum age for implantable devices

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentMedStar Family Choice MarylandPolicy 1421

Hearing Aid Coverage

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 1421 alerts

Get alerted when Policy 1421 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerMedStar Family Choice Maryland

PolicyHearing Aid Coverage

Policy CodePolicy 1421

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit an audiologist evaluation, including an audiogram, for hearing-aid review.

SourceLink

POLICY UPDATE CHANGES

Updated criteria for auditory osseointegrated devices and bone-anchored hearing aids.

Added a six-month examination and medical-clearance requirement for the applicable BAHA criterion.

Under 21Children may qualify for hearing aids

40 dB HLAdult unilateral PTA threshold

5 yearsMinimum age for implantable devices

Maximum age of medical examination

9Explicit limitations or exclusions

Hearing Aid and Implantable Device Coverage

Children Under 21 Years of Age

Covered when ALL of the following criteria are met:

ALL of the following

The participant has a diagnosis of hearing loss with a hearing loss of 25 dB HL or greater.
The hearing aid(s) are recommended and fitted by an audiologist.
For initial hearing aid(s), written medical clearance is obtained from a physician who has performed a medical examination within the past 6 months.

Adults 21 Years of Age and Older — Unilateral Hearing Aids

Covered when ALL of the following criteria are met:

ALL of the following

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.
Documentation shows that the participant is alert and able to utilize the hearing aid appropriately.
The hearing aid is recommended and fitted by an audiologist.
For an initial hearing aid, written medical clearance is obtained from a physician who has performed a medical examination within the past 6 months.

Adults 21 Years of Age and Older — Bilateral Hearing Aids

Bilateral hearing aids are covered when ALL unilateral hearing-aid criteria are met and at least ONE of the following additional criteria is met:

ALL of the following

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.
Documentation shows that the participant is alert and able to utilize the hearing aid appropriately.
The hearing aids are recommended and fitted by an audiologist.
For initial hearing aids, written medical clearance is obtained from a physician who has performed a medical examination within the past 6 months.
ONE of the following

Replacement of hearing aids is not covered when the existing devices are functional, repairable, and appropriately correct or ameliorate the problem or condition.

Replacement of improperly fitted earmold(s) is not covered unless the replacement service is administered by someone other than the original provider and the replacement service has not been claimed before.

Additional professional fees and overhead charges for a new hearing aid are not covered when a dispensing-fee claim has been made to the program.

Loaner hearing aids are not covered.

Hearing aids that are not FDA approved are not covered.

Hearing aids that are not listed on the Maryland Medicaid Audiology Services Fee Schedule are not covered.

Audiology services that are not listed on the Maryland Medicaid Audiology Services Fee Schedule are not covered.

Use of hearing aids for conditions other than hearing loss, including but not limited to tinnitus, is not covered.

Masking devices are not covered.

Requests that do not meet the specified hearing-loss, device, fitting, medical-clearance, or other coverage criteria are not covered.

Clinical Thresholds and Coding Reference

Children’s hearing-aid hearing loss

Minimum hearing loss25 dB HL or greater

Eligible hearing-aid typeBilateral or unilateral hearing aids

PopulationChildren under 21 years of age

Adult unilateral hearing-aid PTA

Better-ear PTA threshold40 dB HL or greater

Test frequencies500, 1,000, 2,000, and 3,000 Hz

Population and measurement earAdults 21 years of age and older; threshold measured in the better ear

Authorization and Documentation Requirements

Prior Authorization

Medical Necessity Authorization

Hearing aids are authorized only when medically necessary for a covered diagnosis of hearing loss and the applicable criteria are met. Requests that do not specifically meet the criteria may be submitted with supporting medical records and relevant literature for Medical Director review as a medical exception.

Children under 21: Bilateral or unilateral hearing aids require hearing loss of at least 25 dB HL.
Adults 21 and older: Unilateral hearing aids require a pure-tone average threshold of at least 40 dB HL at 500, 1,000, 2,000, and 3,000 Hz in the better ear.
The hearing aid must be recommended and fitted by an audiologist, and initial devices require written physician medical clearance based on an examination within the prior six months.

Documentation Required

Audiologist Evaluation and Audiogram Required

Submit an audiologist evaluation and audiogram with the hearing-aid request for review.

Hearing Loss and Hearing Aid Use

Hearing loss may be sensorineural, conductive, or mixed. Hearing aids may help children and motivated, independent adults whose hearing loss interferes with school, work, or other activities. Coverage depends on hearing-loss severity, age, ability to use the device, audiologist recommendation and fitting, and documented medical need for bilateral or bone-anchored technology.

Clinical Terms

dB HL

TermdB HL

MeaningDecibels hearing level

UseUnit used to describe hearing-loss thresholds

Pure Tone Average (PTA)

TermPure Tone Average (PTA)

DefinitionAverage of hearing-threshold levels

Calculation conceptThe average is calculated across a specified set of frequencies

Policy Summary

PayerMedStar Family Choice Maryland

PolicyHearing Aid Coverage

Policy CodePolicy 1421

Change TypeMaterial revision

Effective DateJuly 1, 2026

Last ReviewJul 1, 2025

Next Review DateN/A

Key ActionSubmit an audiologist evaluation, including an audiogram, for hearing-aid review.

SourceLink

On This Page

The participant has visual impairment meeting the definition of statutory blindness.

The participant is a previous successful bilateral hearing-aid user, and meaningful objective benefit to the participant over unilateral amplification can be documented.

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.

Pediatric unilateral BAHA bone-conduction threshold

BAHA Attract, BAHA Divino, BAHA BP100, Baha 4, Sophono Alpha SystemPure-tone average bone-conduction threshold ≤45 dB at 500, 1,000, 2,000, and 3,000 Hz

BAHA 5 Power, BAHA Intenso, Ponto Plus PowerPure-tone average bone-conduction threshold ≤55 dB at 500, 1,000, 2,000, and 3,000 Hz

BAHA Cordelle IIPure-tone average bone-conduction threshold ≤65 dB at 500, 1,000, 2,000, and 3,000 Hz

Pediatric bilateral BAHA symmetry

Average interaural differenceLess than 10 dB averaged at 500, 1,000, 2,000, and 4,000 Hz

Individual-frequency differenceLess than 15 dB at individual frequencies

Applicable devicesBAHA Divino, Ponto Plus, Ponto Plus Power, Ponto Pro, and Sophono Alpha System

Pediatric bilateral BAHA symmetry

Average interaural differenceLess than 10 dB averaged at 500, 1,000, 2,000, and 3,000 Hz

Individual-frequency differenceLess than 15 dB at individual frequencies

Applicable devicesBAHA Attract, BAHA BP100, BAHA 4, BAHA 5 Power, BAHA Cordelle II, and BAHA Intenso

Hearing-loss classification

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 or greater

The evaluation and audiogram must support the applicable hearing-loss and device criteria.

Documentation Required

Initial Medical Clearance

For an initial hearing aid, obtain written medical clearance from a physician who performed a medical examination within the past six months.

This requirement applies to initial hearing aids for children and adults.
For pediatric auditory osseointegrated devices or BAHA, written physician clearance based on an examination within the past six months is also required.

Documentation Required

Adult Ability to Use Device

For an adult unilateral hearing aid, document that the participant is alert and able to utilize the aid appropriately.

Include clinical documentation supporting the participant’s ability to use the device appropriately.

Documentation Required

Adult Bilateral-Use Justification

Adult bilateral hearing aids require that the unilateral-hearing-aid criteria are met plus documentation of at least one qualifying condition demonstrating the need for bilateral amplification.

Statutory blindness or other visual impairment meeting the definition of statutory blindness.
Previous successful bilateral hearing-aid use with meaningful objective benefit over unilateral amplification.
Significant hearing-related disability in educational, vocational, or community settings with a unilateral aid and documented meaningful objective benefit from bilateral aids.

Documentation Required

Pediatric Bilateral BAHA Documentation

For children under 21, bilateral BAHA implants require moderate-to-severe bilateral symmetric conductive or mixed hearing loss meeting the applicable bone-conduction thresholds in both ears. Unilateral implants require conductive or mixed hearing loss meeting the device-specific threshold.

BAHA devices are covered for members age 5 and older; nonimplantable or soft-band devices may be covered for participants younger than 5 or when clinically indicated.
Unilateral bone-conduction thresholds at 500, 1,000, 2,000, and 3,000 Hz must be ≤45 dB for BAHA Attract, BAHA Divino, BAHA BP100, Baha 4, and Sophono Alpha; ≤55 dB for BAHA 5 Power, BAHA Intenso, and Ponto Plus Power; or ≤65 dB for BAHA Cordelle II.
For bilateral implants, symmetry is less than a 10 dB average interaural difference or less than a 15 dB difference at individual frequencies, using the frequency set applicable to the device.

Documentation Required

Conventional Hearing-Aid Contraindication

Document a medical condition that prevents use of a conventional air-conduction hearing aid before requesting a pediatric BAHA or auditory osseointegrated device.

Congenital atresia or surgically induced ear-canal malformation in which the canal is absent or cannot accommodate a standard hearing aid, provided the nerve is functional.
Severe chronic infection of the middle or outer ear.
Dermatitis of the external ear canal, including hypersensitivity to air-conduction hearing-aid ear molds.
Tumor of the external ear canal or tympanic cavity.
Another anatomic or medical condition that contraindicates use of an air-conduction hearing aid.

Denial Risk

Noncovered Device, Service, or Indication

Requests are not covered when the device, service, or indication falls outside the plan’s approved coverage requirements.

Hearing aids must be FDA approved and listed in the Maryland Medicaid Audiology Services Fee Schedule.
Audiology services must be listed in the Maryland Medicaid Audiology Services Fee Schedule.
Hearing aids used for conditions other than hearing loss, including tinnitus, are not covered.
Masking devices are excluded.
Cochlear-implant device-implantation procedures are subject to separate InterQual criteria.

Denial Risk

Unwarranted Replacement

Replacement hearing aids may be denied when the existing devices are functional, repairable, and appropriately correct or ameliorate the member’s hearing problem or condition.

Document why replacement is necessary rather than repair or continued use of the existing device.

Billing Rule

Duplicate or Loaner Charges

Additional charges may be denied when they duplicate covered dispensing or device-related billing.

Additional professional fees and overhead charges for a new hearing aid are not covered when a dispensing-fee claim has already been made to the program.
Loaner hearing aids are not covered.
Replacement of an improperly fitted ear mold is excluded unless administered by someone other than the original provider and the replacement service has not previously been claimed.

Note

Criteria Exception Review

A request that does not specifically meet the stated criteria may be considered as a medical exception by a Medical Director.

Submit supporting medical records explaining the exception and relevant articles or other literature supporting medical necessity.
The exception request remains subject to Medical Director review and is not automatically covered.

Statutory blindness

Better-eye acuityCentral visual acuity of 20/200 or less

CorrectionMeasured with the use of a correcting lens

Statutory referencesSections 216(i)(1) and 1614(a)(2) of the Social Security Act

Sensorineural hearing loss

Affected structureInner ear

CochleaHearing loss may involve the cochlea

Auditory nerveHearing loss may involve the auditory nerve

Conductive hearing loss

DefinitionLimitation of external sound reaching the inner ear

ExampleCerumen impaction

Other examplesMiddle-ear fluid or ossicular-chain fixation, meaning lack of movement of the small ear bones

Mixed hearing loss

DefinitionA combination of conductive and sensorineural hearing loss

Conductive componentInvolves limited transmission of external sound to the inner ear

Sensorineural componentInvolves the inner ear, cochlea, or auditory nerve

Symmetric bone-conduction threshold

Average interaural limitLess than 10 dB average difference between ears at the frequencies specified for the applicable device group

Individual-frequency limitLess than 15 dB difference at individual frequencies

Frequency sets500, 1,000, 2,000, and 4,000 Hz for one device group; 500, 1,000, 2,000, and 3,000 Hz for the other