(A) Definition. "Basic hearing test" is an
evaluation of an individual's ability to hear that includes the following
components:
(1) Testing of air-conducted
stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand
Hz, and four thousand Hz;
(2)
Assessment of air-conducted speech awareness or speech reception
threshold;
(3) Establishment of
most comfortable and most uncomfortable listening levels;
(4) Pure-tone bone conduction audiometry
(unless the individual's age or capability precludes such testing);
and
(5) For an individual younger
than twenty-one years of age, the following components:
(a) Tympanometry;
(b) Acoustic reflex battery; and
(c) Otoacoustic emissions testing.
(B) Coverage.
(1) The default certificate of medical
necessity (CMN) form is the ODM 01915, "Certificate of Medical Necessity:
Hearing Aids" (rev. 7/2018).
(2) A
completed CMN, signed and dated not more than ninety days before the requested
dispensing date,
must be
is accompanied by a hearing evaluation report,
compiled not more than six months before the requested dispensing date, made up
of the following components:
(a) A detailed
description of the hearing test, signed by the physician specializing in
otology or otolaryngology, audiologist, or licensed hearing aid fitter who
administered it;
(b) A copy of the
hearing test results; and
(c) A
written summation of the hearing test results, prepared and signed by a
physician specializing in otology or otolaryngology or by an
audiologist.
(3) Separate
payment may be made for the hearing test itself,. All hearing tests must
be administered by authorized individuals working within their scope
of practice and must be conducted in an
appropriate sound environment in accordance with nationally accepted standards.
Hearing tests should be performed on both ears; a detailed explanation
must be included in a PA request
is needed if bilateral testing cannot be
done.
(4) The need for a hearing
aid is demonstrated when the results of a basic hearing test performed on one
ear indicate the following minimum best pure-tone average hearing loss:
(a) Thirty-one decibels (dB); or
(b) In an individual younger than twenty-one
years of age, twenty-six dB.
(5)
To assess the
performance and acceptability of the hearing aid, the provider must attempt to
schedule a follow-up visit with the individual within thirty days after
delivery. No claim for payment should be submitted during this period. The
provider must keep on file, for at least four years, either a confirmation of
the follow-up visit signed by the individual or an explanation of why the visit
was not conducted. If as a result of the follow-up visit the hearing aid is
deemed unacceptable by either the provider or the individual, then payment is
limited to the cost of the earmold insert and batteries. In such an instance,
if payment has already been made for the hearing aid, then the provider must
arrange for adjustment of the claim.
A claim
for payment should be submitted only after the acceptability of the hearing aid
has been confirmed, usually during a follow-up visit scheduled within thirty
days after delivery. The individual may instead confirm acceptability by
waiving the follow-up visit. In either case, the provider maintains relevant
documentation. If the hearing aid is deemed unacceptable by either the provider
or the individual, then payment is limited to the cost of the earmold insert
and batteries. If payment has already been made for the hearing aid, then the
claim is to be adjusted.
(6)
The following warranty periods apply:
(a) For
a covered hearing aid, it is the greater of the manufacturer's warranty period
or one year from the date of delivery; and
(b) For an earmold insert, it is ninety
days.
(7) A warranty
comprehensively covers the following services:
(a) Repair, including labor and parts (except
earmold inserts and batteries);
(b)
Replacement necessitated by damage or loss; and
(c) Two adjustments per year for changes in
hearing sensitivity or growth of the ear canal (after which additional
adjustments made during the year will be treated as repairs).
(8) A programmable hearing aid,
such as a hearing aid employing contralateral routing of signal (CROS) or
binaural contralateral routing of signal (BiCROS), may be indicated if an
individual has a documented need for such technology in noisy or otherwise
adverse hearing environments.
(9)
Separate payment may be made for the taking of an impression for an earmold
insert (other than an insert dispensed with a hearing aid). Such payment is
limited neither by the place of service nor by the individual's living
arrangement.
(10) Regardless of how
a hearing aid was purchased, payment may be made for necessary repair only if
the following conditions are satisfied:
(a)
The medical necessity of the hearing aid has been established;
(b) The repair is not covered by warranty or
insurance; and
(c) The repair is
not associated with routine maintenance or cleaning of the hearing
aid.
(C)
Requirements, constraints,
Constraints and limitations.
(1) The provider
must keep on file
department may at any time
ask a provider to produce a copy of the manufacturer's original cost
estimate, a copy of the manufacturer's final invoice detailing discounts and
shipping costs, and (if applicable) an explanation of any differences between
the figures.
(2) No payment will be
made for the following hearing aids:
(a) A hearing aid designed to be
worn inside the ear canal;
(b)(a) A disposable
hearing aid; and
(c)(b) A hearing aid that
has been previously used by another individual.
(3) No payment (including payment of a
deductible amount) will be made for replacement if either of the following
conditions is satisfied:
(a) The hearing aid
is covered by warranty or insurance; or
(b) Repair or reconditioning would be more
cost-effective.
(4)
Concurrent requests or claims for two separate hearing aids will be treated as
a single request or claim for a binaural hearing aid.
(5) Payment for a hearing aid includes the
following items:
(a) A cleaning
kit;
(b) An initial earmold insert
(applicable to behind-the-ear hearing aids); and
(c) One month's supply of
batteries.
(6) Payment
for hearing aid dispensing includes the following services:
(a) The taking of initial earmold
impressions;
(b) Assistance with
selection of the hearing aid;
(c)
Up to three hours of counseling;
(d) All visits (including travel) necessary
for the dispensing and fitting of the hearing aid (regardless of place of
service); and
(e) All service calls
and follow-up visits during the warranty period.