ModifiedUnitedHealthcarePolicy ENT 020.27

Otoacoustic Emissions Testing (for Oxford Only)

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This Oxford medical policy governs coverage of otoacoustic emissions testing for neonatal screening, diagnostic hearing evaluation, and ototoxicity monitoring. It identifies medically necessary indications, directs preventive screening for ages 91 days through 21 years to the Preventive Care Services policy, and considers testing unproven and not medically necessary for other populations and conditions.

Policy Summary

PayerUnitedHealthcare

PolicyOtoacoustic Emissions Testing (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified — annual coding update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore deciding coverage, check the member-specific benefit plan document and any applicable federal or state mandates.

SourceLink

POLICY UPDATE CHANGES

The applicable ICD-10 diagnosis code list was updated to reflect annual edits and added Z77.40, Z77.41, and Z77.42.

Updated the applicable ICD-10 diagnosis code list to reflect annual coding edits and added Z77.40, Z77.41, and Z77.42.

90 daysNeonatal screening age limit

91 days–21 yearsPreventive screening referral age

10Diagnostic indications

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ModifiedUnitedHealthcarePolicy ENT 020.27

Otoacoustic Emissions Testing (for Oxford Only)

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Sign up for UnitedHealthcare Policy ENT 020.27 alerts

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Policy Summary

PayerUnitedHealthcare

PolicyOtoacoustic Emissions Testing (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified — annual coding update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore deciding coverage, check the member-specific benefit plan document and any applicable federal or state mandates.

SourceLink

POLICY UPDATE CHANGES

The applicable ICD-10 diagnosis code list was updated to reflect annual edits and added Z77.40, Z77.41, and Z77.42.

Updated the applicable ICD-10 diagnosis code list to reflect annual coding edits and added Z77.40, Z77.41, and Z77.42.

90 daysNeonatal screening age limit

91 days–21 yearsPreventive screening referral age

10Diagnostic indications

3 addedNew diagnosis codes

Medical Necessity and Coverage Criteria

Preventive neonatal hearing screening

Covered as a preventive service when the applicable age and service criteria are met.

Neonatal preventive screening

OAE neonatal hearing screening is proven and medically necessary for infants aged 90 days or younger.Age 90 days or younger
For preventive hearing screening using OAEs for individuals 91 days to 21 years of age, refer to the Preventive Care Services policy.

Diagnostic OAE testing

Diagnostic OAE testing is proven and medically necessary when performed to evaluate hearing loss and at least one listed indication is present.

At least one diagnostic indication

The patient is an infant over 90 days old or a child up to 4 years of age who did not pass or receive an initial hearing screening.
The patient is an infant over 90 days old or a child up to 4 years of age who passed neonatal hearing screening and has a family history of early-, progressive-, or delayed-onset permanent childhood hearing loss.
The patient is a child or adult who is unable to cooperate with other methods of hearing testing, such as an individual with autism or stroke.
The patient is a child with a developmental or delayed speech or language disorder.
The patient has acoustic trauma, noise-induced hearing loss, or sudden hearing loss.
The patient has auditory neuropathy or auditory processing disorder, also known as central auditory processing disorder.
The patient has sensorineural hearing loss confirmed by audiometry.
The patient has abnormal auditory function studies or a failed hearing examination.
The patient may be feigning a hearing loss.
The testing is for monitoring ototoxicity before, during, or after administration of agents known to be ototoxic, such as aminoglycosides or chemotherapy agents.

Tinnitus limitation: Otoacoustic emissions testing should not be offered as part of an investigation of tinnitus unless the tinnitus is accompanied by other symptoms and signs.

FDA approval or clearance alone does not establish coverage. The marketing authorization or clearance of an otoacoustic emissions device is not, by itself, a basis for coverage under this policy.

Auditory screening or diagnostic testing using OAEs is considered unproven and not medically necessary for all other populations and conditions outside the listed medically necessary indications because of insufficient evidence of efficacy.

Procedure and Diagnosis Coding

OAE Procedure CodesCPTCovered

92558	Evoked otoacoustic emissions, screening; automated analysis.
92587	Distortion product evoked otoacoustic emissions; limited evaluation (3–6 frequencies), or transient evoked otoacoustic emissions, with interpretation and report.
92588	Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (minimum of 12 frequencies), with interpretation and report.

Applicable ICD-10-CM Diagnosis CodesICD-10

A17.0	Tuberculous meningitis.
A39.0	Meningococcal meningitis.
A52.13	Late syphilitic meningitis.
A80.0	Acute paralytic poliomyelitis, vaccine-associated.
A80.1	Acute paralytic poliomyelitis, wild virus, imported.
A80.2	Acute paralytic poliomyelitis, wild virus, indigenous.
A80.30	Acute paralytic poliomyelitis, unspecified.
A80.39	Other acute paralytic poliomyelitis.
A80.9	Acute poliomyelitis, unspecified.
A87.0	Enteroviral meningitis.

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Applicable ICD-10-CM Diagnosis CodesICD-10

G00.1	Pneumococcal meningitis.
G00.2	Streptococcal meningitis.
G00.3	Staphylococcal meningitis.
G00.8	Other bacterial meningitis.
G00.9	Bacterial meningitis, unspecified.
G01	Meningitis in bacterial diseases classified elsewhere.
G02	Meningitis in other infectious and parasitic diseases classified elsewhere.
G03.0	Nonpyogenic meningitis.
G03.1	Chronic meningitis.
G03.2	Benign recurrent meningitis [Mollaret].

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Applicable ICD-10-CM Diagnosis CodesICD-10

H83.02	Labyrinthitis, left ear.
H83.03	Labyrinthitis, bilateral.
H83.3X2	Noise effects on left inner ear.
H83.3X3	Noise effects on inner ear, bilateral.
H90.41	Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side.
H90.42	Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side.
H90.5	Unspecified sensorineural hearing loss.
H90.6	Mixed conductive and sensorineural hearing loss, bilateral.
H90.8	Mixed conductive and sensorineural hearing loss, unspecified.
H90.A11	Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side.

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Applicable ICD-10-CM Diagnosis CodesICD-10

H91.02	Ototoxic hearing loss, left ear.
H91.03	Ototoxic hearing loss, bilateral.
H91.21	Sudden idiopathic hearing loss, right ear.
H91.22	Sudden idiopathic hearing loss, left ear.
H91.8X2	Other specified hearing loss, left ear.
H91.8X3	Other specified hearing loss, bilateral.
H93.012	Transient ischemic deafness, left ear.
H93.013	Transient ischemic deafness, bilateral.
H93.212	Auditory recruitment, left ear.
H93.213	Auditory recruitment, bilateral.

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Cerebrovascular Sequelae — Nontraumatic Subarachnoid HemorrhageICD-10

I69.010	Attention and concentration deficit following nontraumatic subarachnoid hemorrhage.
I69.012	Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage.
I69.013	Psychomotor deficit following nontraumatic subarachnoid hemorrhage.
I69.014	Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage.
I69.015	Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage.
I69.018	Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage.
I69.019	Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage.
I69.020	Aphasia following nontraumatic subarachnoid hemorrhage.
I69.021	Dysphasia following nontraumatic subarachnoid hemorrhage.
I69.022	Dysarthria following nontraumatic subarachnoid hemorrhage.

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Cerebrovascular Sequelae — Nontraumatic Intracerebral HemorrhageICD-10

I69.111	Memory deficit following nontraumatic intracerebral hemorrhage.
I69.112	Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage.
I69.113	Psychomotor deficit following nontraumatic intracerebral hemorrhage.
I69.114	Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage.
I69.115	Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage.
I69.121	Dysphasia following nontraumatic intracerebral hemorrhage.
I69.122	Dysarthria following nontraumatic intracerebral hemorrhage.
I69.123	Fluency disorder following nontraumatic intracerebral hemorrhage.

Cerebrovascular Disease SequelaeICD-10

I69.012	Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage.
I69.013	Psychomotor deficit following nontraumatic subarachnoid hemorrhage.
I69.014	Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage.
I69.015	Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage.
I69.018	Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage.
I69.019	Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage.

Associated Conditions, Symptoms, and Hearing FindingsICD-10

R41.89	Other symptoms and signs involving cognitive functions and awareness.
R42	Dizziness and giddiness.
R47.01	Aphasia.
R47.02	Dysphasia.
R47.1	Dysarthria and anarthria.
R49.1	Aphonia.
R62.0	Delayed milestone in childhood.
R94.120	Abnormal auditory function study.
R94.121	Abnormal vestibular function study.
R94.128	Abnormal results of other function studies of ear and other special senses.

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Ear Injury, Cervical Fracture, and Spinal Cord InjuryICD-10

S09.20XA	Traumatic rupture of unspecified ear drum, initial encounter.
S09.21XA	Traumatic rupture of right ear drum, initial encounter.
S09.22XA	Traumatic rupture of left ear drum, initial encounter.
S09.311A	Primary blast injury of right ear, initial encounter.
S09.312A	Primary blast injury of left ear, initial encounter.
S09.313A	Primary blast injury of ear, bilateral, initial encounter.
S09.319A	Primary blast injury of unspecified ear, initial encounter.
S14.101A	Unspecified injury at C1 level of cervical spinal cord, initial encounter.
S14.102A	Unspecified injury at C2 level of cervical spinal cord, initial encounter.
S14.103A	Unspecified injury at C3 level of cervical spinal cord, initial encounter.

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Burns and Corrosions of EarICD-10

T20.011S	Burn of unspecified degree of right ear, sequela.
T20.012S	Burn of unspecified degree of left ear, sequela.
T20.019S	Burn of unspecified degree of unspecified ear, sequela.
T20.111S	Burn of first degree of right ear, sequela.
T20.112S	Burn of first degree of left ear, sequela.
T20.119S	Burn of first degree of unspecified ear, sequela.
T20.312S	Burn of third degree of left ear, sequela.
T20.319S	Burn of third degree of unspecified ear, sequela.
T20.411S	Corrosion of unspecified degree of right ear, sequela.
T20.412S	Corrosion of unspecified degree of left ear, sequela.

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Drug Toxicity, Trauma, Screening, Exposure, and HistoryICD-10

T36.5X1A	Poisoning by aminoglycosides, accidental, initial encounter.
T36.5X1D	Poisoning by aminoglycosides, accidental, subsequent encounter.
T36.5X1S	Poisoning by aminoglycosides, accidental, sequela.
T36.5X2A	Poisoning by aminoglycosides, intentional self-harm, initial encounter.
T36.5X2D	Poisoning by aminoglycosides, intentional self-harm, subsequent encounter.
T36.5X2S	Poisoning by aminoglycosides, intentional self-harm, sequela.
T36.5X3A	Poisoning by aminoglycosides, assault, initial encounter.
T36.5X3D	Poisoning by aminoglycosides, assault, subsequent encounter.
T36.5X3S	Poisoning by aminoglycosides, assault, sequela.
T36.5X4A	Poisoning by aminoglycosides, undetermined, initial encounter.

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Additional Coding ClarificationsICD-10

I97.811	Intraoperative cerebrovascular infarction during other surgery.
I97.820	Postprocedural cerebrovascular infarction following cardiac surgery.
P11.1	Other specified brain damage due to birth injury.

Applicable ICD-10 Diagnosis Codes Added in the 2026 RevisionICD-10

Z77.40	Contact with and suspected exposure to unspecified blast overpressure.
Z77.41	Contact with and suspected exposure to low-level blast overpressure.
Z77.42	Contact with and suspected exposure to high-level blast overpressure.

Added Applicable ICD-10 Diagnosis CodesICD-10

Z77.40	Contact with and suspected exposure to unspecified blast overpressure.
Z77.41	Contact with and suspected exposure to low-level blast overpressure.
Z77.42	Contact with and suspected exposure to high-level blast overpressure.

Diagnostic OAE Frequency Range

Screening OAE frequenciesTEOAE devices use a broad frequency range; diagnostic DPOAE evaluation may be limited to 3–6 frequencies (CPT 92587) or comprehensive with a minimum of 12 frequencies (CPT 92588).

OAE Interpretation

Hearing level associated with absent normal OAE responsesApproximately 30 to 40 dB hearing level or higher

Newborn Screening

Maximum inpatient newborn screening attemptsA maximum of two screening attempts during the inpatient stay

Timing of Initial Newborn Hearing Screening

Provider and Coverage Actions

Documentation Required

Verify Member-Specific Benefits

Before determining coverage, verify the member-specific benefit plan and any applicable federal or state mandates. If the member-specific plan conflicts with this policy, the member-specific plan governs.

Denial Risk

Unlisted Populations or Conditions

Auditory screening or diagnostic testing using OAEs for populations or conditions not specifically listed as medically necessary is unproven and not medically necessary due to insufficient evidence of efficacy.

Denial Risk

Tinnitus Without Accompanying Signs or Symptoms

Clinical Background

Otoacoustic emissions (OAEs) are sounds generated by the inner ear in response to acoustic stimulation. The measurements assess the response of the cochlear outer hair cells and can be obtained without requiring a behavioral response from the patient, allowing testing while the patient is asleep or otherwise unable to cooperate.

Definitions and Technical Concepts

Auditory Neuropathy

Primary findingHearing loss occurs even though the outer hair cells within the cochlea are present and functional

Transmission problemSound information is not faithfully transmitted to the auditory nerve and brain

Other namesAlso known as auditory neuropathy, auditory dyssynchrony, or auditory neuropathy spectrum disorder

Otoacoustic Emissions

What it assessesA test that checks the inner ear response to sound

Behavioral requirementThe test does not rely on the person’s response behavior

Testing condition

Policy Summary

PayerUnitedHealthcare

PolicyOtoacoustic Emissions Testing (for Oxford Only)

Policy CodePolicy N/A

Change TypeModified — annual coding update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore deciding coverage, check the member-specific benefit plan document and any applicable federal or state mandates.

SourceLink

On This Page

Initial newborn hearing screeningBefore 1 month of age; preferably before discharge from the birth hospital

Timing of Diagnostic Evaluation After a Failed Screen

Diagnostic evaluation after a failed screenAs soon as possible and no later than 3 months of age

Do not offer OAE testing solely to investigate tinnitus. OAE testing may be considered only when tinnitus is accompanied by other symptoms and signs.

Denial Risk

FDA Approval Does Not Establish Coverage

FDA approval or clearance of an auditory testing device alone is not a basis for coverage. Coverage depends on the applicable benefit plan and medical-necessity criteria.

The person being tested can be sound asleep during the test

Sensorineural Hearing Loss

Affected structuresDamage may involve the inner ear, or cochlea, or the nerve pathways from the inner ear to the brain

PermanenceMost of the time, sensorineural hearing loss cannot be medically or surgically corrected

Clinical classificationIt is the most common type of permanent hearing loss

Degree of Hearing Loss

Normal hearing−10 to 15 dB HL

Slight through moderate lossSlight: 16–25 dB HL; mild: 26–40 dB HL; moderate: 41–55 dB HL

Moderately severe through profound lossModerately severe: 56–70 dB HL; severe: 71–90 dB HL; profound: 91 dB HL or more

Otoacoustic emissions (OAEs)

Physiologic responseOAEs are physiological measurements of cochlear outer hair-cell responses to acoustic stimuli

Clinical useThey are used to assess cochlear integrity and preneural function

Scope of detectionThe test detects hearing disorders affecting the cochlea and the pathway to the inner ear

Evoked otoacoustic emissions

DefinitionEvoked OAEs are OAEs recorded in response to auditory signals

Signal deliveryAuditory signals may be delivered as a series of very brief clicks to the ear

Measurement siteThe signals are delivered through a probe inserted in the outer third of the ear canal

OAE pass/fail or refer result

Pass resultThe monitor displays “pass” when the emission is adequate

Fail or refer resultThe monitor displays “fail” or “refer” when dysfunction or blockage prevents measurement of the emission

Interpretive limitationA fail or refer result may reflect a problem along the pathway to the cochlea

Otoacoustic emissions (OAEs)

MeasurementOAEs are physiological measurements of cochlear outer hair-cell responses to acoustic stimuli

AssessmentThey are used to assess cochlear integrity and preneural function

Hearing-system informationOAEs reflect inner-ear mechanics and provide information that further defines auditory-system integrity and sensitivity

Evoked otoacoustic emissions

DefinitionEvoked OAEs are emissions recorded in response to auditory signals

Probe componentsThe probe typically contains loudspeakers that generate the signals and a microphone that measures the resulting OAEs

Recording locationThe probe is inserted in the outer third of the ear canal

Transient evoked otoacoustic emissions (TEOAEs)

StimulusTEOAE devices emit a single brief click

Frequency coverageThe click covers a broad frequency range

UsesTEOAEs are used to screen infants, validate other tests, and assess cochlear function

Distortion product otoacoustic emissions (DPOAEs)

StimulusDPOAE devices emit two brief tones set at two separate frequencies

Cochlear assessmentDPOAEs are used to assess cochlear damage

Additional usesDPOAEs are used to assess ototoxicity and noise-induced damage

Auditory neuropathy (AN)

Disorder typeAuditory neuropathy is a neural disorder

Auditory brainstem responseIt may present with an absent or very abnormal auditory brainstem response

OAE findingThe OAE reading may remain normal because the cochlear outer hair cells are working normally