CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ear Surgical Services and Hearing Aid Benefits — Coverage Criteria

Defines coverage, limitations, exclusions, and billing codes for ear-related surgical services, hearing aids (monaural and binaural), and hearing aid services for Neighborhood Health Plan of Rhode Island members in specified benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEar Surgical Services and Hearing Aid Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient hospitalizations and for additional hearing aids requested within a three-year rolling period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pair / 3 yrsHearing aid benefit frequency allowance

All inpatient staysRequire prior authorization

Separate benefitCochlear implants

Multiple rangesCoding enumerated

Coverage Criteria

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Covered Services

Coverage includes the following when applicable:

Covered categories: Surgical services of the ear, hearing aids (monaural and binaural), and hearing aid services are covered benefits for listed member benefit packages.

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

Coverage conditions

Prior authorization: All inpatient hospitalizations for ear services require medical review and prior authorization.
Experimental/non‑FDA: Experimental procedures and non‑FDA approved services are not covered unless provided for the treatment of cancer.
Cosmetic exclusion: Cosmetic ear surgery and procedures are not covered.

Hearing aid frequency: The hearing aid benefit allows one pair of hearing aids per three rolling years; additional hearing aids within a three‑year period require prior authorization.1 pair / 3 years

Prior authorization required for additional devices within the three‑year rolling period.

Extended Family Planning (EFP) members are excluded from the comprehensive ear benefit package and do not have access to the full set of ear-related covered services.

All inpatient hospitalizations for ear services require medical review and prior authorization. Requests for services that are experimental or not FDA-approved are not covered except when used for the treatment of cancer. Cosmetic ear surgery and cosmetic procedures are excluded from coverage.

Cosmetic ear surgeries and cosmetic procedures are not covered under this policy. Experimental procedures and non–FDA approved services are also not covered, except when provided as part of cancer treatment.

These exclusions apply in addition to the specific member-level exclusion for Extended Family Planning (EFP) members, who do not have the comprehensive ear benefit package.

Coding and Billing Codes

Surgical CPT/HCPCS CodesCPTCovered

69000-69020	Surgical Services Ear CPT range
69100-69222	Surgical Services Ear CPT range
69310-69700	Surgical Services Ear CPT range
69720-69915	Surgical Services Ear CPT range
69950-69990	Surgical Services Ear CPT range
G0268	Surgical Services Ear HCPCS
69000	Example individual CPT within listed ranges

Hearing Aids - Monaural HCPCSHCPCSCovered

V5242-V5247	Hearing Aids - Monaural HCPCS range
V5254-V5257	Hearing Aids - Monaural HCPCS range

Hearing Aids - Binaural and additional HCPCSHCPCSCovered

V5070,V5080,V5100,V5120,V5150,V5170,V5180,V5190,V5210,V5220,V5230	Hearing Aids - Binaural HCPCS codes
V5248-V5253	Hearing Aids - Binaural HCPCS range
V5258	Hearing Aids - Binaural HCPCS (listed)
V5264,V5265,V5266,V5275	Additional Hearing Aid Services HCPCS codes listed in continuation

Hearing Aid Services CPT/HCPCSmixedCovered

92590-92595	Hearing Aid Services CPT range (audiology)
S0618,V5010,V5011,V5014,V5020,V5110,V5160,V5200,V5240,V5241	Hearing Aid Services HCPCS and related codes

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required for Inpatient Stays

Prior authorization is required for all inpatient hospitalizations. Failure to obtain prior authorization may result in claim denial or delay in payment.

All inpatient hospitalizations require medical review and PA

Denial Risk

Non‑covered Experimental / Non‑FDA Services

The plan does not cover experimental procedures or services that are not FDA‑approved. An exception applies when such services are provided for the treatment of cancer.

Non‑FDA approved or experimental services are not covered unless used for cancer treatment

Documentation Required

Required Documentation for Prior Authorization Requests

Documentation must be submitted to support prior authorization requests, including clinical rationale, relevant medical records, and any diagnostic testing results. For requests for additional hearing aids within a three‑year rolling period, include prior device history and justification for medical necessity.

Submit clinical notes, diagnostic test results, and prior device history (when applicable)
Include justification for medical necessity for additional hearing aids within 3 years

Prior Authorization

Hearing Aid Limits and Prior Authorization

The Hearing Aid Benefit is limited to one pair of hearing aids per rolling three‑year period. Requests for additional hearing aids within three years require prior authorization and supporting documentation; services provided without prior authorization may be denied.

One pair of hearing aids per 3 rolling years
Additional hearing aids within 3 years require PA and supporting documentation

Denial Risk

Cosmetic Exclusion

Cosmetic ear surgeries and procedures are excluded from coverage and may be denied.

Cosmetic ear surgeries/procedures are not covered

Background

Services for the ear encompass a broad range of diagnostic and surgical procedures involving the external, middle, and inner ear. Covered categories within the ear benefit include surgical ear services, monaural and binaural hearing aids, and hearing aid services. Cochlear implants and related prostheses are managed under a separate Implants Benefit Coverage Summary and are not adjudicated through this ear services policy.

Operational limits and program rules include a Hearing Aid Benefit frequency of one pair per three rolling years, and a requirement that all inpatient hospitalizations undergo medical review and prior authorization. Experimental or non–FDA approved procedures are excluded except when used for cancer treatment, and cosmetic procedures are not covered.

Definitions

Services for the ear — definitions and implant references

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

Covered categoriesSurgical services of the ear; hearing aids (monaural and binaural); and hearing aid services are covered for listed member benefit packages (RIte Care; Children with Special Health Care Needs; Substitute Care; Rhody Health Partners; Rhody Health Options Phase One).

Implants referenceCochlear implants and prostheses are managed under the separate Implants Benefit Coverage Summary.

Benefit packagesRIte Care; Children with Special Health Care Needs; Substitute Care; Rhody Health Partners; Rhody Health Options Phase One.