Hearing Aids

3. Hearing Aids

The hearing aid should be adequate for the member’s condition and a reasonable expenditure as well.

An invoice must be submitted with claims for monaural hearing aids with a submitted charge of $401 or more and binaural hearing aids with a submitted charge of $802 or more.

If a hearing aid is returned to the provider within the allowable period of time, the provider should return the aid to the manufacturer. Notify the IME Provider Services Unit of the situation. Include copies of claims and invoices, remittance statements, and any peer review documentation. An adjustment to the payment for the hearing aid will be made.

a. Binaural Amplification

Binaural amplification is covered when suitable for bilateral hearing loss. Examples include:

♦ The aid is for a blind person

♦ The aid is needed for educational or vocational purposes 

♦ Lack of binaural amplification poses a hazard to a member’s safety 

♦ The member’s hearing loss has caused marked restriction of daily activities and constriction of interests, resulting in seriously impaired ability to relate to other people

The member record must document the reason for binaural hearing aids.

b. Dispensing Service

A dispensing service is covered to allow for the fitting and adjustment of the hearing aid when one is provided. It is considered to include follow up services for the first six months after the aid is provided.

When the member is unable to travel to the provider’s business due to medical reasons, the U-3 modifier should be used. Dispensing fees should be billed as follows:

Procedure                      Code Description 

V5241                       Monaural hearing aid 

V5241-U3                 Monaural hearing aid, nursing home 

V5160                       Binaural hearing aids 

V5160-U3                 Binaural hearing aids, nursing home 

When binaural hearing aids are appropriate but the member prefers to receive only one hearing aid initially and later returns for the second aid for binaural hearing, the monaural dispensing code should be billed for each hearing aid.

c. Ear Molds, Replacement

Payment for a service charge in addition to the cost of material for ear molds is allowed if it is the provider’s practice to make such a service charge to the general public. 

When a service charge is made, it is considered to include all functions performed in connection with fitting of the ear mold, including travel, if necessary. Therefore, no additional charge may be made to the member or others for the service.

d. Maintenance Items

Maintenance items, such as batteries, cords, and dry storage devices are payable when obtained from a participating provider. An invoice must be included with claims with a submitted charge of $51 or more.

Dispensing of hearing aid batteries is considered a service and must be documented in the member’s chart with the date of service and number of batteries dispensed. Up to 30 hearing aid batteries are covered within a 90-day period for a member with a monaural hearing aid. Up to 60 hearing aid batteries are covered within a 90-day period for a member with binaural hearing aids.

e. Prior Authorization

Prior authorization is required for the following: 

♦ A monaural hearing aid costing more than $650

♦ Binaural hearing aids costing more than $1,300 

♦ Replacement of a hearing aid in less than four years for members 21 years of age and older 

♦ FM systems