Bone Anchored Hearing Aids (BAHA) and Partially-Implantable Magnetic Bone Conduction Hearing Aids Policy Number: 2016M0023A Effective Date: 5/14/2018 Review Date: 4/27/2018 Next Review Date: 5/14/2020 1 P a g e Important Information - Please Read Before Using This Policy UCare has developed medical policies to assist in the determination of coverage of a clinical service (such as a procedure, therapy, diagnostic test, medical device, etc.), when coverage requires determination of medical necessity. Clinical services referenced in UCare s medical policies may not be covered by every UCare plan. Coverage is determined by federal and state regulation and by member contract materials, such as the Evidence of Coverage (EOC), Member Contract, or Member Handbook. This medical policy alone does not guarantee coverage. Coverage is subject to the benefits or restrictions of the member s specific plan, which will supersede this medical policy when applicable. Please refer to the end of this document to read How Coverage Is Determined in Specific UCare Plans. UCare s medical policies are periodically reviewed and updated using published clinical evidence. In addition to medical policies, UCare uses tools for determination of medical necessity that are developed by external sources, including but not limited to McKesson InterQual Criteria and Hayes Inc. Knowledge Center. This medical policy does not constitute the practice of medicine or medical advice. Treating health care providers are solely responsible for determining what care to provide to patients. Members should always consult their provider before making any decisions about medical care. Administrative Procedure Prior authorization is NOT required for bone anchored hearing aids for Minnesota Health Care Programs or Medicare Plans. UCare may review medical records after the procedure to confirm that medical necessity criteria were met. Choices plan coverage may vary, please refer to the plan documents. CPT codes are listed below in the codes section. Although prior authorization is not required, providers may submit clinical information to confirm
medical necessity criteria are met using the prior authorization form below. UCare prior authorization form is available here: https://www.ucare.org/providers/eligibility-authorizations/pages/eligibilityauth.aspx Definitions and Scope of this Policy Audiologic Evaluation: A hearing test completed by an audiologist or otolaryngologist to evaluate communication problems caused by hearing loss. Bone-Anchored Hearing Aids: (also called osseointegrated implants) External bone-conduction Hearing Aids function by transmitting sound waves through the bone to the ossicles of the middle ear. Binaural : Refers to both ears. Conductive Hearing Loss: Occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones (ossicles) of the middle ear. Hearing Aids: Hearing Aids are sound-amplifying devices designed to aid people who have a hearing impairment. They are either air conduction Hearing Aids or bone conduction Hearing Aids. Mixed Hearing Loss: Occurs when a conductive hearing loss occurs in combination with a sensorineural hearing loss (SNHL). In other words, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. Monaural: Refers to only one ear. Partially-Implantable Electromagnetic Hearing Aids: Uses two magnetic fields to cause vibration of the ossicle and transmission of sound to the inner ear. Pure Tone Hearing Test: measure the faintest level (hearing threshold) at which a tone can be heard at selected frequencies approximately 50% of the time. Each ear is tested separately. The pure tone average threshold hearing level is calculated separately for each ear by averaging the hearing levels at each frequency. Sensorineural Hearing Loss (SNHL): Occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain. This is the most common type of permanent hearing loss. 2 P a g e
Medical Necessity Criteria Bone Anchored Hearing Aid and Partially-Implantable Magnetic Bone Conduction Hearing Aids Unilateral or bilateral fully- or partially- implantable bone-conduction (bone-anchored) Hearing Aid(s) may be considered medically necessary in patients who have a hearing loss and can still benefit from sound amplification. Unilateral or bilateral fully- or partially implantable bone-conduction (boneanchored) Hearing Aid(s) may be considered medically necessary as an alternative to an air-conduction Hearing Aid in patients 5 year of age and older with a conductive or mixed hearing loss when both of the following criteria (A and B) are met: A. At least one of the following criteria is met: Congenital or surgically induced malformations (e.g., atresia) of the external ear canal or middle ear; Chronic external otitis or otitis media; Tumors of the external canal and/or tympanic cavity; Dermatitis of the external canal. Patients who are candidates for an air-conduction contralateral routing of signals (AC CROS) Hearing Aid but who cannot or will not wear an AC CROS device B. One of the following audiologic criteria is met: A pure tone average bone-conduction threshold measured at 0.5, 1, 2, and 3 khz of db lower than or equal to 45 db (OBC, BP100, Baha4 and Baha5 devices), 55 db (BP110 and Intenso devices), or 65 db (Cordele II device) in patients with unilateral hearing loss (see Policy Guidelines below); or For bilateral implantation, patients should have a symmetrically conductive or mixed hearing loss (measured without augmentation) as defined by a difference between left and right side bone conduction threshold of less than 10 db on average measured at 0.5, 1, 2 and 3 khz (4 khz for OBC, Ponto Pro, and Otomag Alpha 1 [M]), or less than 15 db at individual frequencies. A fully- or partially-implantable bone-conduction (bone-anchored) 3 P a g e
Hearing Aid may be considered medically necessary as an alternative to an air-conduction contralateral routing of signals Hearing Aid in patients 5 years of age and older with single-sided sensorineural deafness and normal hearing in the other ear. A transcutaneously worn, non-surgical application of an implantable Bone-Anchored Hearing Aid (bone conduction-type Hearing Aid) utilizing a headband or Softband is considered medically necessary as an alternative to an implantable Bone-Anchored Hearing Aid or air-conduction Hearing Aid in individuals who meet criteria I. or II., above, except for the age limitation of 5 years of age or older which does not apply for a transcutaneously worn Bone-Anchored Hearing Aid. Implant replacement with a next-generation device may be considered medically necessary only in the small subset of patients whose response to existing components is inadequate to the point of interfering with activities of daily living, which would include school and work; or when components are no longer functional. Replacement parts or upgrades to existing Bone-Anchored Hearing Aids and/or components that are currently functional are considered not medically necessary, including but not limited to when requested for convenience or technology upgrade. Replacement parts or upgrades include, but are not limited to batteries, processors, headbands or Softbands. 4 P a g e
Applicable Codes Applicable Codes The Current Procedural Terminology (CPT ) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other medical policies and coverage determination guidelines may apply. CPT Code Ranges Applicable To This Policy 69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone 69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69718 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69799 Partially-implantable Electromagnetic Hearing Aids. Unlisted procedure, middle ear. 92590 Hearing Aid examination and selection; monaural 92591 Hearing Aid examination and selection; binaural 92592 Hearing Aid check; monaural 92593 Hearing Aid check; binaural 92594 Electroacoustic evaluation for Hearing Aid; monaural 92591 Electroacoustic evaluation for Hearing Aid; binaural HCPCS Code Ranges Applicable To This Policy L8690 L8691 L8692 L8693 L8694 S2230 V5011 5 P a g e Auditory osseointegrated device, includes all internal and external components use for BAHA system Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment Auditory osseointegrated device abutment, any length, replacement only Auditory osseointegrated device, transducer/actuator, replacement only Implantation of magnetic component of partially-implantable hearing device on ossicles in middle ear Hearing Aid checks or reprogramming performed by a Hearing Aid dispenser. Cannot be billed with 92592 and 92593. Refer to the Audiology Service Thresholds when service is
V5014 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5095 V5100 V5110 V5120 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210 V5220 V5230 V5240 V5241 V5242 V5243 V5244 V5245 V5246 V5267 V5247 V5252 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 6 P a g e performed by an audiologist. Repair/modification of a Hearing Aid Monaural, body worn, air conductive Monaural, body worn, bone conductive Monaural, ITE Monaural, BTE Hearing Aid in glasses, air conductive Hearing Aid in glasses, bone conductive Dispensing fee, unspecified Hearing Aid - use when dispensing FM system or vibrotactile device Partially-implantable middle ear hearing prosthesis Hearing Aid, bilateral, body worn Dispensing fee, bilateral Binaural, on-the-body Binaural, ITE Binaural, BTE Hearing Aid in glasses, binaural Dispensing fee, binaural CROS, ITE CROS, BTE CROS, in glasses Dispensing fee, CROS BiCROS, ITE BiCROS, BTE BiCROS, in glasses Dispensing fee, BiCROS Dispensing fee, monaural Hearing Aid, any type Analog, Monaural CIC Hearing Aid, analog, monaural, in the canal Hearing Aid, digitally programmable analog, monaural, completely in ear canal (CIC) Hearing Aid, digitally programmable analog, monaural, in the canal (ITC) Monaural ITE, digitally programmable analog Hearing Aid supplies and accessories, not otherwise specified (for example, rechargeable batteries, chest harness, telecoils) Monaural BTE, digitally programmable analog, monaural, ITE Binaural ITE, digitally programmable Digitally Programmable Analog, Monaural CIC Digitally Programmable Analog, Monaural ITC Hearing Aid, digitally programmable analog, monaural, ITE Hearing Aid, digitally programmable analog, monaural, behind the ear (BTE) Hearing Aid, analog, Binaural CIC Analog, Monaural ITC Hearing Aid, Digitally Programmable Analog, Binaural CIC Hearing Aid, Digitally Programmable Analog, Binaural ITC Hearing Aid, Digitally Programmable Analog, Binaural ITE Hearing Aid, Binaural BTE, digitally programmable, binaural, BTE Digital, Monaural CIC Digital, Monaural ITC
V5256 Monaural ITE, digital ITE V5257 Monaural BTE, digital BTE V5258 Digital, Binaural CIC V5259 Digital, Binaural ITC V5260 Binaural ITE, digital ITE V5261 Binaural BTE, digital BTE V5262 Disposable, Monaural, any type V5263 Disposable, Binaural, any type V5264 Ear mold/insert, not disposable, any type V5265 Ear mold/insert, disposable, any type V5266 Battery for use in hearing device (standard batteries only) V5267 Hearing Aid or assistive listening device/supplies/accessories, not otherwise specified. V5268 Assistive Listening Device, telephone amplifier, any type V5269 Assistive listening device, alerting type, any type V5270 Assistive listening device, television amplifier, any type V5271 Assistive listening device, television caption decoder V5272 Assistive listening device, TDD V5273 Assistive listening device, for use with cochlear implant V5274 Assistive listening device, not otherwise specified (fuse for vibrotactile devices and pocket talkers V5275 Ear impressions, each V5281 Assistive listening device, personal FM/DM system, monaural, (1 receiver, transmitter, microphone), any type V5282 Assistive listening device, personal FM/DM system, binaural, (2 receivers, transmitter, microphone), any type V5283 Assistive listening device, personal FM/DM neck, loop induction receiver V5284 Assistive listening device, personal FM/DM, ear level receiver V5285 Assistive listening device, personal FM/DM, direct audio input receiver V5286 Assistive listening device, personal blue tooth FM/DM receiver V5287 Assistive listening device, personal FM/DM receiver, not otherwise specified V5288 Assistive listening device, personal FM/DM transmitter assistive listening device V5289 Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any type V5290 Assistive listening device, transmitter microphone, any type V5298 Hearing Aid not otherwise classified V5299 Miscellaneous Hearing Aid servicing CPT is a registered trademark of the American Medical Association. How Coverage Is Determined In Specific UCare Plans Commercial: UCare Choices/Fairview UCare Choices: Coverage is determined by the Member Contract. If there is a conflict between this medical policy and the individual Member Contract, the provisions of the Member Contract will govern. 7 P a g e
Medicare Advantage: UCare for Seniors (HMO Point-of-Service) and EssentiaCare (Preferred Provider Organization) Coverage is determined by guidance from the Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) or applicable CMS Local Coverage Determination (LCD) and the applicable UCare Evidence of Coverage (EOC). This medical policy applies in the absence of CMS guidance and/or EOC language. Medicaid MinnesotaCare: Prepaid Medical Assistance Program (PMAP), UCare Connect (non-snp/non-integrated), Minnesota Senior Care Plus (MSC+), and MinnesotaCare Coverage is determined by the applicable Evidence of Coverage (also known as the Member Handbook ) and guidance from the Minnesota Department of Human Services (DHS) Minnesota Health Care Programs (MHCP) Provider Manual. This medical policy applies if DHS coverage criteria are not available. Medicare Advantage Dual Eligible Special Needs Plan: UCare Connect + Medicare and Minnesota Senior Health Options (MSHO) Medicare coverage is determined by the applicable Member Handbook (MSHO) or Evidence of Coverage (UCare Connect + Medicare) and guidance from the Centers for Medicare & Medicaid Services (CMS). This medical policy applies in the absence of CMS guidance and/or EOC language. Medicaid coverage is determined by the applicable Member Handbook (MSHO) or Evidence of Coverage (UCare Connect + Medicare), and guidance from the DHS MHCP Provider Manual. This medical policy applies if coverage criteria have not been determined by DHS. Revision History 2/1/2016 Policy number 2013M0023B 4/27/2018 8 P a g e