CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ear Coverage Summary 08.23.12 Through 09.30.21

Defines coverage, limitations, exclusions, and billing code groupings for surgical ear services, hearing aids (monaural and binaural), and hearing aid services for specified Rhode Island Medicaid managed care benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEar Coverage Summary 08.23.12 Through 09.30.21

Policy CodePolicy N/A

Change TypeInformational (version history only)

Effective Date

Next Review Date

Key ActionObtain medical review and prior authorization for all inpatient hospitalizations related to ear services.

SourceLink

POLICY UPDATE CHANGES

Version history shows creation date 2010-06-10 and revision dates including 08/23/12; PEC review date 10/03/13.

3Covered Indication Categories

1 per 3 yearsHearing aid frequency benefit

EFP excludedPopulation exclusion

Coverage Summary

Scope: Defines coverage, limitations, exclusions, and billing code groupings for surgical ear services, hearing aids (monaural and binaural), and hearing aid services for specified Rhode Island Medicaid managed care benefit packages.

Medical Necessity, Coverage Limitations & Exclusions

Coverage Limitations

Services are covered subject to the following limitations and requirements:

ALL of the following

All inpatient hospitalizations require medical review and prior authorization
Prior authorization required for all inpatient ear-related hospitalizations
Experimental/non-FDA-approved services: All experimental procedures and non FDA approved services are not covered unless for the treatment of cancer
Experimental/non-FDA-approved services covered only when treatment of cancer
Cosmetic procedures: Cosmetic surgery and procedures are not covered
Cosmetic ear procedures excluded
Hearing aid frequency: The Hearing Aid Benefit allows one pair of hearing aids per three rolling years1 per 3 years
Additional hearing aids within a three-year period require prior authorization

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Coding — grouped by code category

Surgical Services Ear - CPT rangeCPTCovered

69000-69020	CPT range as listed in policy
69100-69222	CPT range as listed in policy
69310-69700	CPT range as listed in policy
69720-69915	CPT range as listed in policy
69950-69990	CPT range as listed in policy

Surgical Services Ear - HCPCSHCPCSCovered

G0268

Ear surgical services HCPCS code listed

Surgical Services Ear - ICD-9 Procedure rangeICD-10Covered

18.02-18.4	ICD-9 procedure code ranges listed
18.6-20.94	ICD-9 procedure code ranges listed

Hearing Aids - Monaural HCPCSHCPCSCovered

V5242-V5247	Monaural hearing aid HCPCS range
V5254-V5257	Monaural hearing aid HCPCS range

Hearing Aids - Binaural HCPCSHCPCSCovered

V5070	Binaural hearing aid HCPCS codes listed
V5080
V5100
V5120
V5150
V5170
V5180
V5190
V5210
V5220

1–10 of 13

1/2

Hearing Aid Services - CPTCPTCovered

92590-92595

Hearing aid services CPT range

Hearing Aid Services - HCPCS and S-codesmixedCovered

S0618	Hearing aid services code
V5010
V5011
V5014
V5020
V5110
V5160
V5200
V5240
V5241

1–10 of 14

1/2

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization for inpatient hospitalizations

Obtain medical review and prior authorization for all inpatient hospitalizations related to ear services.

Prior Authorization

Prior authorization for additional hearing aids within 3 years

Obtain prior authorization for hearing aids when more than one pair is requested within a rolling three-year period (hearing aid benefit allows one pair per three rolling years).

Denial Risk

Experimental/non-FDA-approved procedures exclusion

Claims for experimental procedures and non–FDA-approved services are not covered and will be denied unless provided for the treatment of cancer.

Denial Risk

Cosmetic procedures exclusion

Claims for cosmetic ear surgery and procedures are not covered and are subject to denial.

Background

Services for the ear include a broad range of surgical services and procedures involving the external, middle and inner ear.

Cochlear implants and prostheses are addressed under a separate Implants Benefit Coverage Summary.

Applicable benefit packages include: RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, and Rhody Health Options Phase One.

Coverage includes: Surgical Services Ear, Hearing Aids — Monaural and Binaural, and Hearing Aid Services with associated CPT/HCPCS/ICD-9 code groupings as listed in the policy tables.

Coverage limitations include: prior authorization and medical review for all inpatient hospitalizations; experimental/non‑FDA‑approved services not covered unless for cancer treatment; cosmetic ear procedures excluded; and the Hearing Aid Benefit allows one pair of hearing aids per three rolling years (additional hearing aids within three years require prior authorization). Extended Family Planning (EFP) members are excluded from this benefit.

Ear services: Surgical services and procedures involving the external, middle and inner ear.

Revision History

2010-06-10version history

Version created (Create Date: 06/10/10); informational, no clinical policy statement changes indicated.

2010-10-22version history

Revision recorded (Revision Date: 10/22/10); informational, no clinical policy statement changes indicated.

2010-11-30version history

Revision recorded (Revision Date: 11/30/10); informational, no clinical policy statement changes indicated.

2012-08-23version history

Revision recorded (Revision Date: 8/23/12); informational, no clinical policy statement changes indicated.

2013-10-03version historyLatest

PEC review date recorded (PEC Review Date: 10/3/13); informational, no clinical policy statement changes indicated.