COVERAGE OF SERVICES

1. Audiologist

Services provided by an audiologist are covered subject to the following limitations.

a. Audiological Testing

Payment will be approved for testing performed by an audiologist to establish the member’s need for a hearing aid. Covered testing services are:

♦ Hearing evaluation, which must include bone conduction and air conduction tests 

♦ Speech audiometry 

♦ Hearing aid selection

The services of the audiologist also include at least one visit with the patient after the purchase of the hearing aid to determine whether the device is functioning adequately.

No payment is to be made to audiologists for services before the member’s examination by a physician, except as noted under Physician Examination.

A physician referral is required when comprehensive audiometry threshold evaluation and recognition, procedure code 92557 is provided to Medicare and Medicaid dual eligibles. The claim must first be submitted to Medicare for those members. A copy of the Medicare Explanation of Medicaid Benefits (EOMB) must be included with the Medicaid claim.

No payment is made for duplicate testing procedures.

b. Cerumen Removal

Removal of impacted cerumen (69210) is considered included with reimbursement for hearing testing and should not be separately billed. It is covered when otherwise medically necessary. The “SC” modifier should be used when billing for members who are eligible for both Medicare and Medicaid.

c. Newborn and Infant Hearing Screening

All newborns and infants born in Iowa, except those born with a condition that is incompatible with life, must be screened for hearing loss.

The primary goals for the EHDI program are: 1 month All infants will be screened for hearing loss before 1 month of age, preferably before hospital discharge. 3 months All infants who do not pass the screening will have diagnostic audiologic evaluation before 3 months of age. 6 months All infants identified with hearing loss receive appropriate early intervention services before 6 months of age.

d. Travel 

Travel by the audiologist to perform testing services may be approved when the member is unable to travel due to medical reasons. Travel will be approved only from the provider’s local base of operation to the member’s home or care facility.

e. Vestibular Testing 

Payment will be approved for vestibular function tests when prescribed by a physician to evaluate problems with vertigo and balance

2.FM Systems 

FM systems require prior authorization and may be allowed for children who use hearing aids but need additional amplification in settings such as a classroom. The device should be billed using V5274 for the FM system and V5299 for the dispensing fee.