CurrentUnitedHealthcarePolicy CS052KY.11

Hearing Instruments and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Kentucky Only)

Kentucky-specific UnitedHealthcare Community Plan medical policy describing coverage rationale, references to InterQual clinical criteria for wearable air-conduction, bone-anchored, and semi-implantable devices, definitions, FDA/clinical evidence summaries, and an applicable CPT/HCPCS/V code list. Also lists devices considered unproven/not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicyHearing Instruments and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Kentucky Only)

Policy CodePolicy CS052KY.11

Change TypeRevised CPT code list; administrative archival

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must refer to and meet InterQual CP clinical criteria for the specified device categories to establish medical necessity.

POLICY UPDATE CHANGES

Updated list of applicable CPT codes to reflect quarterly edits; added 0951T–0955T (Policy history entry dated 12/01/2025).

Archived previous policy version CS052KY.10.

3Device categories covered with InterQual criteria

3Device types listed as unproven/not medically necessary

60+Listed CPT/HCPCS/V codes referenced

5New CPT codes added

Coverage Summary

This Kentucky-specific policy (CS052KY.11) covers wearable air-conduction, bone-anchored/bone conduction, and semi-implantable middle-ear hearing devices and references the InterQual clinical criteria as the determinant of medical necessity for each device category. Wearable air-conduction hearing aids are described as proven and medically necessary when InterQual Durable Medical Equipment: Hearing Aids criteria are met; bone-anchored/bone conduction devices and semi-implantable middle-ear devices are covered when InterQual Procedures criteria for those device types are satisfied.

The policy also lists several device types that are considered unproven and not medically necessary (intraoral bone conduction instruments, laser/light-based instruments, and totally implanted middle-ear systems) due to insufficient or conflicting evidence. Device-specific FDA indications, audiometric thresholds, age requirements, and symmetry criteria are summarized in the policy and must be documented to establish candidacy.

Quick facts & device/code counts

Device categories covered with InterQual criteria3

Device types listed as unproven/not medically necessary3

Listed CPT/HCPCS/V codes referenced60+

Devices discussed (examples)BAHA, Ponto, Bonebridge, Osia, ADHEAR, Esteem, Earlens, SoundBite

New CPT codes added (12/01/2025)5

Medical-Necessity Criteria (InterQual-referenced)

Covered when medical necessity criteria met (referenced InterQual criteria)

Coverage is provided when the referenced InterQual clinical criteria are met for the specific device type:

Device categories covered with InterQual criteria

Wearable air-conduction hearing aids are proven and medically necessary for correction of a hearing impairment when InterQual CP: Durable Medical Equipment, Hearing Aids criteria are met.
Bone anchored hearing aid / bone conduction hearing aid: medical necessity clinical coverage criteria per InterQual CP: Procedures: Hearing Device, Bone Anchored or Bone Conduction (adult and pediatric).
Semi-implantable hearing aids (middle ear): medical necessity clinical coverage criteria per InterQual CP: Procedures, Hearing Device, Middle Ear.

Device-specific FDA Indications (summarized per device)

Not Medically Necessary / Unproven Devices

Not medically necessary / Unproven

The following devices are considered unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Intraoral bone conduction/SoundBite: Intraoral bone conduction hearing instruments (e.g., SoundBite) - insufficient quality evidence.
Laser/light-based/Earlens: Laser or light-based hearing instruments (e.g., Earlens Contact Hearing Device) - limited evidence and lack of concurrent control groups.
Totally implanted middle ear systems: Totally implanted middle ear hearing instruments/systems - insufficient quality evidence; conflicting findings and reported adverse events identified.

Coding (CPT / HCPCS / V / L / S codes)

CPT codes (surgical/implantation/testing) referencedCPT

69710	Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone
69714	Implantation, osseointegrated implant, skull, with percutaneous attachment to external speech processor
69716	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or resulting in removal of less than 100 sq mm surface area of bone deep to the outer cranial cortex
69717	Replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor
69719	Revision or replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex
69729	Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex
69730	Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex
92590	Hearing aid examination and selection; monaural
92591	Hearing aid examination and selection; binaural
92592	Hearing aid check; monaural

1–10 of 19

1/2

HCPCS / CPT Category II / V / S / L codes (hearing aids and components)mixed

L8690	Auditory osseointegrated device, includes all internal and external components
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each
L8693	Auditory osseointegrated device abutment, any length, replacement only
L8694	Auditory osseointegrated device, transducer/actuator, replacement only, each
S0618	Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
V5010	Assessment for hearing aid
V5011	Fitting/orientation/checking of hearing aid
V5014	Repair/modification of a hearing aid
V5020	Conformity Evaluation
V5264	Ear mold/insert, not disposable, any type

1–10 of 60

1/6

Applicable CPT codes (updated list per Policy History)CPT

0951T	Added to applicable CPT codes per 12/01/2025 summary
0952T	Added to applicable CPT codes per 12/01/2025 summary
0953T	Added to applicable CPT codes per 12/01/2025 summary
0954T	Added to applicable CPT codes per 12/01/2025 summary
0955T	Added to applicable CPT codes per 12/01/2025 summary

Provider Actions & Billing Guidance

Documentation Required

Use InterQual criteria for medical necessity determinations

Refer to the specified InterQual CP clinical criteria for Durable Medical Equipment: Hearing Aids; Procedures: Hearing Device, Bone Anchored or Bone Conduction (adult and pediatric); and Procedures: Hearing Device, Middle Ear when determining medical necessity. Meeting the applicable InterQual criteria is required for coverage determinations.

Documentation Required

Document device-specific audiometric thresholds and age

Document the patient’s age and the device-specific pure tone average (PTA) bone conduction and/or air conduction thresholds, and document interaural (left-right) symmetry where applicable to align with FDA indications referenced in this policy.

See device-specific PTA BC/AC threshold and symmetry requirements in the thresholds and device indication sections (e.g., BAHA, Bonebridge, Osia/Osia 2).

Background, Evidence Summary, and Definitions

Background: This policy applies only in Kentucky and uses InterQual clinical criteria as the primary reference for coverage determinations for wearable air-conduction hearing aids, bone-anchored/bone conduction devices, and semi-implantable middle-ear devices.

The policy summarizes FDA clearances/approvals and device-specific indications: bone-anchored systems (BAHA and successors) with historical PTA BC thresholds (e.g., ≥ 45 dB HL indications and specifications for bilateral symmetry and single-sided deafness), partially and non-implantable bone-conduction options (Ponto, Bonebridge, Osia systems) with age and PTA BC thresholds (examples include Bonebridge and Osia age ≥ 12 years and PTA BC limits), semi-implantable electromagnetic devices (e.g., Vibrant Soundbridge) with FDA selection ranges and word-recognition requirements, and totally implantable systems (e.g., Esteem) which have FDA approval but an evidence base with mixed results and reported adverse events.

The policy also describes device categories with limited evidence: intraoral bone conduction (SoundBite) and laser/light-based contact hearing devices (Earlens), noting the SoundBite is no longer manufactured and that light-based devices have single-arm trials demonstrating functional gains but limited concurrent control data.

Evidence Item	Summary
SoundBite (IOBC) clinical series	Prospective case series (Gurgel 2015) n=81 showed subjective benefit (APHAB) and high satisfaction but lacked a control group, had withdrawals, and evidence rated low quality
Earlens (light-based CHA) trials	Single-arm studies (Arbogast 2019; Gantz 2017) demonstrated improved functional gain and APHAB scores versus unaided; limitations include lack of blinding and concurrent control groups
Totally implantable middle ear devices	Mixed evidence from small observational studies and systematic reviews showing some functional gain but device failures, adverse events, heterogeneous results, and overall insufficient high-quality evidence
FDA clearance / approval references	Multiple 510(k), de novo, and PMA documents cited for devices (e.g., SoundBite, Earlens, Esteem, BAHA, Osia, Bonebridge) with links and access dates noted
Guideline references	AAO-HNS position statements (2016; bone conduction revised 2021) and various published studies/HTAs cited supporting device considerations

Conductive Hearing Loss: Sound not conducted efficiently through outer/middle ear; often medically or surgically correctable.

Sensorineural Hearing Loss (SNHL): Damage to inner ear or nerve pathways; usually not medically or surgically correctable and is the most common permanent hearing loss.

Mixed Hearing Loss: Combination of conductive and sensorineural hearing loss (damage in outer/middle ear plus inner ear or auditory nerve).

Hearing Aids (for policy): Any wearable instrument/device designed to aid or improve defective human hearing, including semi-implantable electromagnetic and bone-anchored devices (per FDA classification).

Revision History

2025-12-01revisedLatest

Updated list of applicable CPT codes to reflect quarterly edits; added 0951T, 0952T, 0953T, 0954T, and 0955T.

2025-12-01clarified

Archived previous policy version CS052KY.10.

Policy Summary

PayerUnitedHealthcare

PolicyHearing Instruments and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Kentucky Only)

Policy CodePolicy CS052KY.11

Change TypeRevised CPT code list; administrative archival

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must refer to and meet InterQual CP clinical criteria for the specified device categories to establish medical necessity.

On This Page

Coverage considerations reference FDA indications which specify age and audiometric thresholds; devices are intended for patients meeting ALL of the following for each device:

ALL of the following

Patient meets device-specific minimum age requirement (varies by device)
Patient has conductive or mixed hearing loss and can still benefit from sound amplification (device-specific PTA BC threshold requirements apply)
For single-sided deafness (SSD) indications, the contralateral ear must have normal hearing as defined by device-specific PTA AC thresholds
For bilateral fitting, symmetry criteria apply: interaural BC threshold difference usually <10 dB average (0.5,1,2,3 kHz) or <15 dB at individual frequencies
Examples by device (ONE of)
- Ponto / BAHA systems: PTA BC threshold better than or equal to 45 dB HL for specified processors (device/date dependent)<=45 dB HL
- BAHA SoundArc: PTA BC thresholds vary by processor: <=45 dB HL (BP100, Baha 4/5), <=55 dB HL (BP110 Power, Baha 5 Power), <=65 dB HL (Cordelle II, Baha 5 SuperPower)<=45 to <=65 dB HL depending on processor
- Otomag Alpha 1 (Sophono): PTA BC threshold better than 45 dB HL<=45 dB HL
- Cochlear Baha Attract: PTA BC <=45 dB HL for BP100 processor; <=55 dB HL for BP110 processor<=45 or <=55 dB HL
- Bonebridge (MED-EL): age >=12 years; PTA BC <=45 dB HLage >=12; PTA BC <=45 dB HL
- Osia / Osia 2 (Cochlear): age >=12 years; PTA BC <=55 dB HL; fitting range up to 55 dB SNHL; recommended prior experience with appropriately fitted AC or BC hearing aidsage >=12; PTA BC <=55 dB HL
- ADHEAR system: non-invasive; intended for all ages with conductive hearing loss or SSD; PTA BC <=25 dB HL for conductive indication; SSD contralateral AC PTA <=20 dB HLPTA BC <=25 dB HL; contralateral AC <=20 dB HL
- BAHA Softband / Headband / SoundArc: indicated for children including <5 years (Softband) or any age (SoundArc) depending on processorvaries by application
- Esteem (totally implanted middle ear system): FDA approved device (refer to PMA)per PMA
- Earlens Contact Hearing Device: age >=18 years with mild to severe sensorineural hearing impairmentage >=18; mild to severe SNHL

Rationale: available studies for intraoral, light-based, and totally implantable middle-ear devices are limited by small samples, lack of concurrent controls or randomization, and heterogeneous or conflicting findings; device-related adverse events and failures have been reported.

FDA approvals and clinical evidence summaries and additional background are provided in the policy Background/Evidence sections for reference.

Documentation Required

Prior experience with AC or BC hearing aids (recommended for some devices)

For certain implantable bone-conduction systems (for example, Osia and Bonebridge) it is recommended that individuals have prior experience with appropriately fitted air-conduction or bone-conduction hearing aids before implantation. Document any prior trial, demonstrated benefit, or intolerance of AC/BC hearing aids in the record.

Billing Rule

Manual review required for unspecified hearing aid accessory codes

HCPCS code V5267 (Hearing Aid or assistive listening device/supplies/accessories, not otherwise specified) requires manual review to determine the specific item before a coverage determination can be made.

V5267

Billing Rule

Use updated CPT codes

Report procedures using the updated list of applicable CPT codes added to this policy on 12/01/2025. Use the payer's current coding guidance for implants and processors when submitting claims.

0951T
0952T
0953T
0954T
0955T

Documentation Required

State regulation cross-reference

Refer to Kentucky Administrative Regulations (KAR), Title 907, Chapter 001, Regulation 038 for program coverage provisions and requirements relevant to hearing devices.

SSD (Single-Sided Deafness): Profound sensorineural hearing loss in one ear with normal hearing in the opposite ear; 'normal hearing' commonly defined as PTA AC ≤ 20 dB HL (0.5,1,2,3 kHz).

PTA (Pure Tone Average): Average hearing threshold measured at specified frequencies (commonly 0.5, 1, 2, and 3 kHz) used to determine device candidacy.

Key numeric audiometric thresholds

BAHA indication - pure tone threshold>= 45 dB HL

BAHA SSD normal hearing definitionPTA AC <= 20 dB HL (0.5,1,2,3 kHz)

BAHA bilateral symmetry criterion<10 dB average difference (0.5,1,2,4 kHz) or <15 dB at individual frequencies

Vibrant Soundbridge selection ranges500Hz 30-65 dB; 1kHz 40-75 dB; 1.5kHz 45-80 dB; 2kHz 45-80 dB; 3kHz 50-85 dB; 4kHz 50-85 dB; WRS >=50%

Osia / Osia 2 PTA BC<= 55 dB HL; fitting range up to 55 dB SNHL

Bonebridge PTA BC & age<= 45 dB HL; age >= 12 years

ADHEAR PTA BC (conductive) & SSD contralateral<= 25 dB HL (BC conductive); SSD contralateral AC <= 20 dB HL

Interaural BC threshold symmetry (general)<10 dB average (0.5,1,2,3 kHz) or <15 dB at individual frequencies