CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ear services and hearing aids coverage

Defines coverage, limitations, exclusions, and applicable procedure and supply codes for surgical ear services, hearing aids, 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 services and hearing aids coverage

Policy CodePolicy N/A

Change TypeNo material change

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 period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pair / 3 yrshearing aid benefit frequency

prior authall inpatient hospitalizations

separateimplants benefit

RIte Care etc.benefit packages

Coverage — when services are covered or excluded

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General Coverage: Surgical ear services, hearing aids (monaural and binaural), and hearing aid services are included benefits for listed plan packages (RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners and Rhody Health Options)

See code tables for billed codes

Prior Authorization for Inpatient Care: All inpatient hospitalizations require medical review and prior authorization

Failure to obtain prior authorization may result in denial

Hearing Aid Frequency: One pair of hearing aids is allowed per three rolling years; additional hearing aids within a three-year period require prior authorization1 pair / 3 rolling years

Applies to the hearing aid benefit

Exclusions and Non‑coverage: Experimental or non‑FDA approved services are not covered except when used to treat cancer; cosmetic surgery and procedures are not covered

Extended Family Planning (EFP) members are excluded from the comprehensive benefit package

The policy excludes coverage for cosmetic surgery and cosmetic procedures. In addition, experimental or non–FDA approved services are not covered except when used for the treatment of cancer. These limitations apply to surgical ear procedures, hearing-related technologies, and associated services when the intervention meets the described criteria for being cosmetic or investigational.

Procedure, supply, and billing codes

Surgical CPT/HCPCSCPT|HCPCSCovered

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
69000-69990 (select ranges)	Surgical Services Ear, CPT (document lists multiple contiguous ranges)

Hearing Aids - Monaural HCPCSHCPCSCovered

V5242-V5247, V5254-V5257

Hearing Aids - Monaural HCPCS ranges

Hearing Aids - Binaural HCPCSHCPCSCovered

V5070, V5080, V5100, V5120, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5248-V5253, V5258

Hearing Aids - Binaural HCPCS list/ranges as provided

Hearing Aid Services CPT/HCPCSCPT|HCPCSCovered

92590-92595	Hearing Aid Services, CPT range
S0618, V5010, V5011, V5014, V5020, V5110, V5160, V5200, V5240, V5241, V5264, V5265, V5266, V5275	Hearing Aid Services, HCPCS list

Authorization, documentation, and billing actions required of providers

Prior Authorization

Prior Authorization Required

Prior Authorization Required — All inpatient hospitalizations and additional hearing aids within a 3-year period require prior authorization. Failure to obtain prior authorization may result in claim denial or delayed payment. Providers must request prior authorization before scheduling inpatient ear-related hospitalizations and before dispensing additional hearing aids if the member has received a hearing aid (unilateral or bilateral) within the prior three rolling years.

All inpatient hospitalizations require medical review and prior authorization.
Additional hearing aids within a three-year period require prior authorization (Hearing Aid Benefit: one pair per three rolling years).

Billing Rule

Coding on Claims

Document applicable ICD-9 diagnosis and procedure codes, CPT codes, and HCPCS codes on claims for surgical ear services, hearing aids, and hearing-aid-related services. Include supporting clinical documentation and prior authorization approval numbers when applicable to avoid denials.

Surgical ear CPT range examples: 69000–69020, 69100–69222, 69310–69700, 69720–69915, 69950–69990.
Surgical ear HCPCS: G0268.
Hearing aid HCPCS examples (monaural/binaural and services): V5070, V5080, V5100, V5120, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5240–V5247, V5248–V5253, V5254–V5257, V5258–V5266, V5275, S0618, V5010, V5011, V5014, V5020, V5110, V5160, V5200, V5240, V5241, V5264, V5265, V5266, V5275.
Hearing aid services CPT: 92590–92595.

Documentation Required

Documentation and Billing Requirements

Providers should ensure claims include: patient diagnosis, procedure codes, device HCPCS/CPT, and any prior authorization identifiers. Attach clinical notes supporting medical necessity for surgical procedures and for requests for hearing aids that exceed the standard benefit frequency.

Include ICD-9/ICD-9 procedure codes where applicable for historical claims.
Attach prior authorization approval number to the claim when required.
Provide clinical justification when requesting additional hearing aids within the 3-year limit.

Background and scope of services

Services for the ear covered under this policy encompass a broad range of care including surgical procedures of the external, middle, and inner ear, provision of hearing aids (monaural and binaural), and associated hearing aid services. Cochlear implants and other implantable prostheses are managed under a separate implants benefit. Note that coverage is subject to the policy’s exclusions and limitations, including the EFP exclusion, prior authorization requirements for inpatient hospitalizations, and limits on frequency of hearing aid replacement.

Key definitions

Services for the ear - definition and scope

Scope of ear servicesIncludes surgical services and procedures involving the external, middle, and inner ear

Included service typesSurgical ear services, monaural and binaural hearing aids, and hearing aid services

Benefit packagesRIte Care; Children with Special Health Care Needs (CSHCN); Substitute Care; Rhody Health Partners; Rhody Health Options

Coverage statusCovered benefit when within benefit scope and not excluded

Most actionable item - Definition (highlight)Services for the ear include a broad range of surgical services and procedures involving the external, middle and inner ear