Prior authorization is required for all hearing aids.

Transcription

1 Hearing Aids MP9445 Covered Service: Prior Authorization Required: Additional Information: Medicare Policy: BadgerCare Plus Policy: Yes when meets criteria below Prior authorization is required for all hearing aids. The Hearing Aid Prior Authorization Form is required for all adult and pediatric patients. However, pediatric patients are not required to fill out the Monoaural Hearing Impairment Formula and the Combined Hearing Impairment Formula located on the bottom portion of the form. Prior authorization is dependent on the member s Medicare coverage. Prior authorization is not required for Medicare Cost (Dean Care Gold) and Medicare Supplement (Select) when this service is provided by participating providers. Prior authorization is required if a member has Medicare primary and Dean Health Plan secondary coverage. This policy is not applicable to our Medicare Replacement product (Dean Advantage). Dean Health Plan covers when BadgerCare Plus also covers the benefit. Dean Health Plan Medical Policy: 1.0 Hearing aids are considered medically necessary if they are: 1.1 Supplied to meet the basic hearing needs of the member and 1.2 Required to treat the diagnosis of hearing loss as defined below and 1.3 Prescribed for other than convenience of the member. 2.0 Hearing exams are required and must be performed by a licensed audiologist to evaluate and determine if correction is needed. An initial exam does not require prior authorization but must meet ALL of the following criteria: 2.1 Evaluation by an in-plan audiologist is required and 2.2 Documentation of an audiogram, needs assessment and medical clearance must be within the past 6 months. 3.0 Hearing aids require prior authorization through the Quality and Care Management Division and are a covered when ALL of the following criteria has been met: Hearing Aids 1 of 5

2 3.1 Audiologic testing shows an average hearing loss level of 10% or greater for each ear being supplied with a hearing aid when measured at 1000, 2000, 3000 and 4000 Hertz (Hz) as measured by the Hearing Impairment Calculation (see page 3) and; 3.2 Speech communication is effectively improved with the use of hearing aids or auditory contact is necessary for sound awareness (personal safety) in the environment in which the recipient exists. 3.3 If a unilateral aid is provided but the hearing in the unaided ear deteriorates subsequently, a hearing aid for the second ear may be authorized under criteria in 3.1 or Infants and children through age 18 who are certified as deaf or hearing impaired by a physician or audiologist are eligible for bilateral (both ears) hearing aids. The Hearing Impairment Calculation Worksheet is not required for patients through age The Monoaural Hearing Impairment Formula and the Combined Hearing Impairment Formula found on the Hearing Aid prior authorization form are not required for patients through age The following hearing devices are not covered: 5.1 A fully implantable middle ear hearing aid 5.2 Non-implantable, intraoral bone conduction hearing aid. 6.0 Hearing Aids that can be purchased without a medical evaluation or over the counter are considered not medically necessary, and therefore, are not covered. 7.0 Batteries for hearing aids after the one supplied with the initial aid are not covered. 8.0 All other indications not listed above are considered experimental and investigational, and are not covered. 9.0 Please refer to medical policy Bone Anchored Hearing Aid MP9018 for additional information. Committee/Source Date(s) Originated: Medical Director Committee/ Medical Affairs December 18, 2013 Revised: May 21, 2014 August 20, 2014 October 15, 2014 September 16, 2015 May 18, 2016 December 20, 2017 Hearing Aids 2 of 5

3 Reviewed: Committee/Source Date(s) May 21, 2014 August 20, 2014 October 15, 2014 September 16, 2015 October 21, 2015 May 18, 2016 October 31, 2016 December 20, 2017 Published/Effective: 01/01/2018 Hearing Aids 3 of 5

4 Hearing Aid Prior Authorization Form PATIENT DEMOGRAPHICS Patient Name: Date of Birth: Member ID: Phone Number: Street Address: City: State: Zip Code: REFERRING PROVIDER INFORMATION Provider Name: Phone #: Street Address: Fax #: City: State: Zip Code: Provider #: Specialty: REQUEST INFORMATION Date (s) of Service: Diagnosis Code(s): ICD Code(s): CPT Codes and Description: # of Visits 3 rd party liability: W/C MVA Other The Hearing Impairment Formulas are for adult use only. Monoaural Hearing Impairment Formula A.N.S.I 1969 ([([1000 Hz Hz Hz Hz] 4) 25] x 1.5) = % of loss Left Ear (X) Right Ear (0) Hz db level Hz db level Total Stop here if total is 100 or less Avg threshold for 4 4 = Hearing Aids 4 of 5 Total Stop here if total is 100 or less Avg threshold for 4 4 =

5 frequencies Less threshold fence of 25 db 25 = Multiplied by 1.5 equals the % of monaural loss x 1.5 = Total percent monaural hearing loss frequencies Less threshold fence of 25 db 25 = Multiplied by 1.5 equals the % of monaural loss x 1.5 = Total percent monaural hearing loss *****Stop here if either of the monaural hearing loss % s are zero. ***** ([% better ear x 5] + [% worse ear]) 6 = % of loss Combined Hearing Impairment Formula: % better ear x 5 = Plus % worse ear + Sub -Total Subtotal 6 = % Binaural Hearing Loss Hearing Aids 5 of 5