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    v1.0.28
    OpenPayerPolicy UpdatesOtorhinolaryngology (ENT)Vermont Medicaid Audiology Coverage | OpenPayer
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    CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy 4.213

    Audiology Services

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    This rule governs coverage of audiology services and hearing aids under Vermont Medicaid, including covered services, provider conditions, eligibility criteria, prior authorization guidance, and non-covered items.

    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyAudiology Services
    Policy CodePolicy 4.213
    Change TypeNo material clinical or coverage changes
    Effective DateJan 1, 2020
    Next Review DateN/A
    Key ActionConsult the Vermont Medicaid Fee Schedule to determine covered services and applicable prior authorization requirements.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4Covered audiology service categories
    4Covered hearing-aid service categories
    30 dBHearing-loss threshold

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    50%Repair cost limit
    72%Word-recognition threshold

    Covered Audiology and Hearing-Aid Services

    Covered audiology services

    Audiology services approved for coverage are limited to the following services.

    • Audiologic examinations.
    • Hearing screening.
    • Hearing assessments.
    • Diagnostic tests for hearing loss.

    Covered hearing-aid services

    Covered hearing-aid services include the following.

    • Analog or digital hearing aids, including repair, replacement, or modification.
    • Prescriptions for hearing-aid batteries.
    • Fitting, orientation, and/or checking of hearing aids.
    • Ear molds specific to hearing aids.

    Hearing-aid eligibility

    Hearing aids are covered when at least one of the following conditions is met, or when otherwise medically necessary for a child under age 21.

    At least one of the following

    • Hearing loss in the better ear is greater than 30 dB, based on an average taken at 500, 1000, and 2000 Hz.> 30 dB
    • Unilateral hearing loss is greater than 30 dB, based on an average taken at 500, 1000, and 2000 Hz.> 30 dB
    • Hearing loss in the better ear is greater than 40 dB, based on an average taken at 2000, 3000, and 4000 Hz.> 40 dB
    • Word recognition is poorer than 72%.

    Provider qualification and enrollment

    Covered audiology services must meet the following provider condition.

    Qualified provider: The service is provided by a physician or licensed audiologist working within the scope of practice and enrolled with Vermont Medicaid.

    Hearing-aid repair limitation

    Hearing-aid repairs are subject to the following cost limitation.

    Repair cost limit: The hearing-aid repair cost does not exceed 50% of the replacement cost.Not more than 50% of replacement cost

    Non-medical items and fees associated with hearing-aid selection trial periods or loaners are not covered.

    Clinical Thresholds and Cost Limits

    Better-ear hearing loss
    ThresholdGreater than 30 dB
    Measurement basisAverage hearing loss in the better ear
    Measurement frequencies500, 1000, and 2000 Hz
    Unilateral hearing loss
    ThresholdGreater than 30 dB
    Hearing-loss patternUnilateral hearing loss
    Measurement frequencies500, 1000, and 2000 Hz

    Provider Guidance and Documentation

    Prior Authorization

    Fee Schedule and Prior Authorization

    Review the Vermont Medicaid Fee Schedule for the detailed list of covered audiology services and to determine which services require prior authorization. The Fee Schedule is available on the Department of Vermont Health Access website.

    Documentation Required

    Document Hearing-Loss Measurements

    Document the hearing-loss measurements used to establish hearing-aid eligibility, including the applicable frequency averages and word-recognition result.

    • Hearing loss in the better ear is greater than 30 dB, based on an average at 500, 1000, and 2000 Hz.
    • Unilateral hearing loss is greater than 30 dB, based on an average at 500, 1000, and 2000 Hz.
    • Hearing loss in the better ear is greater than 40 dB, based on an average at 2000, 3000, and 4000 Hz, or word recognition is poorer than 72%.

    Policy Background

    This rule addresses audiology services related to the diagnosis, screening, prevention, and correction of hearing and hearing disorders, including audiologic evaluations and diagnostic services. It also addresses hearing aids, wearable devices used to compensate for impaired hearing, along with specified hearing-aid equipment and related services.

    Key Definitions

    Audiology services
    Service typeDiagnosis of hearing and hearing disorders
    Preventive and evaluative servicesScreening and prevention of hearing and hearing disorders
    Corrective servicesCorrection of hearing and hearing disorders
    Hearing aids
    FormWearable instruments or devices
    PurposeCompensate for impaired hearing
    DefinitionWearable instruments or devices to compensate for impaired hearing
    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyAudiology Services
    Policy CodePolicy 4.213
    Change TypeNo material clinical or coverage changes
    Effective DateJan 1, 2020
    Next Review DateN/A
    Key ActionConsult the Vermont Medicaid Fee Schedule to determine covered services and applicable prior authorization requirements.
    SourceLink
    On This Page
    Covered Audiology and Hearing-Aid ServicesClinical Thresholds and Cost LimitsProvider Guidance and DocumentationPolicy BackgroundKey Definitions
    < 72%
  1. The hearing aid is otherwise medically necessary for a child under age 21.
    2. Better-ear hearing loss at higher frequencies
    ThresholdGreater than 40 dB
    Measurement basisAverage hearing loss in the better ear
    Measurement frequencies2000, 3000, and 4000 Hz
    Word recognition
    ThresholdPoorer than 72%
    MeasurementWord recognition
    Eligibility criterionWord-recognition result is poorer than 72%
    Hearing-aid repair cost
    Maximum repair costMay not exceed 50%
    Comparison basisReplacement cost
    Covered repair limitationHearing-aid repairs are limited to no more than 50% of the replacement cost
    Denial Risk

    Non-Covered Trial and Loaner Charges

    Do not bill Vermont Medicaid for non-medical items or fees associated with hearing-aid selection trial periods or loaners.

    • Non-medical items and fees associated with selection trial periods or loaners are not covered.
    Denial Risk

    Confirm Hearing-Aid Eligibility

    Hearing aids are covered only when the beneficiary meets at least one specified hearing-loss criterion, or when the service is otherwise medically necessary for a child under age 21. Confirm and document medical necessity before submitting a claim.

    • Services must be provided by a physician or licensed audiologist acting within the scope of practice and enrolled with Vermont Medicaid.
    • Coverage requires at least one qualifying hearing-loss condition, unless the hearing aid is otherwise medically necessary for a child under age 21.
    Billing Rule

    Repair Cost Limit

    Hearing-aid repair charges may not exceed 50% of the replacement cost.

    • Limit repair billing to no more than 50% of the replacement cost.