STANDARDS OF COVERAGE - BILATERAL HEARING LOSS
The bilateral hearing loss standards of coverage are as follows: Age Under 21 Years Conventional analog or digital/programmable monaural or binaural hearing aid:
* Bilateral hearing loss documented by an audiogram showing hearing loss of 25 dB HL or greater in both ears using the four frequency average of 500, 1000, 2000 and 4000 Hz; or
* Results of a complete diagnostic audiological evaluation (e.g., auditory brainstem response, evoked otoacoustic emissions, soundfield testing, or any combination of these) indicating a hearing loss of 25 dB HL or greater.
Age 21 Years or Over Conventional analog or digital/programmable monaural hearing aid:
* Bilateral hearing loss documented by an audiogram showing hearing loss of 30 dB HL or greater in both ears using the four frequency average of 500, 1000, 2000, and 4000 Hz; and
* A speech recognition score of at least 20 percent in the ear to be aided. Conventional analog or digital/programmable binaural hearing aid:
* Bilateral hearing loss documented by an audiogram showing hearing loss of 30 dB HL or greater in both ears using the four frequency average of 500, 1000, 2000, and 4000 Hz.
* A speech recognition score must be greater than 20 percent in both ears;
* The four frequency average between ears must not exceed 20 dB HL; and
* The speech recognition scores must not differ between ears by more than 30 percent.
STANDARDS OF COVERAGE - UNILATERAL HEARING LOSS
The unilateral hearing loss standards of coverage for a conventional analog or digital/programmable hearing aid are as follows:
Age Under 21 Years * Hearing loss of 25 dB HL or greater in the ear to be aided with normal hearing in the better ear;
* Speech recognition scores must be greater than 60 percent in the ear to be aided;
and
* The beneficiary must be receiving hearing impaired services through the school system.
Age 21 Years or Over * Hearing loss of 30 dB HL or greater in the ear to be aided with normal hearing in the better ear;
* Speech recognition scores must be greater than 60 percent in the ear to be aided;
* A Hearing Handicap Inventory for the Elderly, Hearing Handicap Inventory for Adults, Adult Performance Hearing Aid Benefit or similar inventory indicates a need for amplification; and
* Hearing aid is required for independent functioning (e.g., effects on employment, communication status).
DOCUMENTATION
Applicable documentation to be maintained in the beneficiary record includes:
* A medical clearance signed and dated by the physician within six months prior to dispensing the hearing aid.
* An audiogram and recommendation of the make, model and type of hearing aid, signed and dated by the audiologist within six months prior to dispensing the hearing aid.
* For hearing aids not covered under the volume purchase contract, a copy of the manufacturer’s invoice showing the hearing aid model, serial number, invoice price, applicable discounts, and shipping and handling charges.
Additional applicable documentation required when a conventional analog or digital/programmable hearing aid is dispensed for unilateral hearing loss includes:
Age Under 21 Years * An audiogram documenting hearing loss of 25 dB HL or greater in the ear to be aided with normal hearing in the better ear.
* Documentation of speech recognition scores greater than 60 percent in the ear to be aided.
* Documentation from the educational system that the child is receiving hearing impaired services.
Age 21 Years or Over * An audiogram documenting hearing loss of 30 dB HL or greater in the ear to be aided, with normal hearing in the better ear.
* Documentation of speech recognition scores greater than 60 percent in the ear to be aided.
* Results of the administration of the Hearing Handicap Inventory for the Elderly, Hearing Handicap Inventory for Adults, Adult Performance Hearing Aid Benefit or similar inventory indicating need for amplification.
* Documentation of requirement for independent functioning (e.g., effects on employment, communication status).
PRIOR AUTHORIZATION REQUIREMENTS
PA is not required for either monaural or binaural conventional analog or digital/programmable hearing aids if all other hearing aid requirements are met and restrictions, i.e., frequency of replacement, are not exceeded.
PA is required for the following:
* Any hearing aid not included in the volume purchase contract.
* Replacement aids within five years.
* Conventional analog and digital/programmable hearing aids for unilateral hearing loss.
The following documentation must be submitted with all PA requests:
* MSA-1653-B.
* Documentation from the manufacturer showing invoice price, discounts, and shipping and handling charges.
* Medical clearance signed by a physician.
* Audiogram completed within the past six months, signed and dated by the audiologist, and including the recommended manufacturer, model and style of hearing aid.
The following additional documentation must be submitted with all PA requests for conventional analog or digital/programmable hearing aids provided for unilateral hearing loss:
Age Under 21 Years * An audiogram documenting hearing loss of 25 dB HL or greater in the ear to be aided, with normal hearing in the better ear.
* Documentation that the ear to be aided has a speech recognition score greater than 60 percent.
* Documentation provided by the educational system that the child is receiving hearing impaired services.
Age 21 Years or Over * An audiogram documenting hearing loss of 30 dB HL or greater in the ear to be aided, with normal hearing in the better ear.
* Documentation that the ear to be aided has a speech recognition score greater than 60 percent.
* Results of administration of the Hearing Handicap Inventory for the Elderly, Hearing Handicap Inventory for Adults, Adult Performance Hearing Aid Benefit, or similar inventory indicating a need for amplification.
* Documentation of requirement for independent functioning (e.g., effects on employment, communication status).
PAYMENT RULES
Payment for any hearing aid not covered under the volume purchase contract is the lesser of the provider’s acquisition cost or Medicaid’s maximum allowable amount.
Acquisition cost consists of the manufacturer’s invoice price, minus any discounts, and includes actual shipping costs.
No comments:
Post a Comment