What is not covered?

The agency does not cover the following hearing and hearing aid-related items and services for clients age 20 and younger:

• Tinnitus maskers 
• Group screenings for hearing loss, except as provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program (refer to the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Billing Guide) 
• FM systems, including the computer-aided hearing devices for FM systems 

When EPSDT applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental. 

Exception to Rule (ETR) 

The agency evaluates a request for medical services, equipment, and/or supplies that are listed as noncovered under the provisions of WAC 182-501-0160 that relates to noncovered services. The request for a noncovered medical service, equipment, or supply is called a “request for an exception to rule.” 

HCPCS

Code                Short Description                                     Policy

L7510              Prosthetic device repair rep                       PA

L8615             Coch implant headset replace                 EPA/PA

L8616             Coch implant microphone repl               EPA/PA

L8617             Coch implant trans coil repl                    EPA/PA

L8618             Coch implant tran cable repl                   EPA/PA

L8619             Coch imp ext proc/contr rplc                       PA

L8621              Repl zinc air battery                               EPA/PA

L8622              Repl alkaline battery                              EPA/PA

L8623              Lith ion batt CID,non-earlvl                  EPA/PA

L8624              Lith ion batt CID, ear level                    EPA/PA

L8627              CID ext speech process repl                       PA

L8628              CID ext controller repl                               PA

L8629              CID transmit coil and cable                        PA

L8691               Osseointegrated snd proc rpl                     PA

L8692                Non-osseointegrated snd proc                  PA

L8693            Auditory osseointegrated device abutment,

                           replacement only                                    PA

L9900                O&P supply/accessory/service               PA

Legend

EPA: Expedited Prior Authorization 

PA: Prior Authorization required

Authorization

What is prior authorization (PA)? 

PA is agency approval for certain medical services, equipment, or supplies, before the services are provided to clients, as a precondition for provider payment.

Does the agency require prior authorization for hearing hardware? (WAC 182-547-1000) 

No. Except for certain services specified in the Coverage table, PA is not required for clients age 20 and younger for hearing aids and services. Providers must send claims for clients age 20 and younger directly to the agency. Providers do not need to obtain authorization from the local Children with Special Health Care Needs (CSHCN) Coordinator. 

Note: The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169. (WAC 182-547-1000 (2)) 

Coverage

Monaural or binaural hearing aids

 The agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear mold and batteries, for eligible clients age 20 and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and be under warranty for a minimum of one year. 

Replacement 

The agency pays for the following replacements as long as the need for replacements is not due to the client’s carelessness, negligence, recklessness, or misuse in accordance with WAC 182- 501-0050(8): 

• Hearing aid(s), which includes the ear mold, when all warranties are expired and the hearing aid(s) are one of the following: 
• Lost 
• Beyond repair 
• Not sufficient for the client's hearing loss 
• Ear mold(s) when the client's existing ear mold is damaged or no longer fits the client's ear. 
• Batteries with a valid prescription from an audiologist. 

Repair 

The agency pays for a maximum of two repairs, per hearing aid, per year, when the repair is less than 50% of the cost of a new hearing aid. To receive payment, all the following must be met: 

• All warranties are expired. 
• The repair is under warranty for a minimum of 90 days.

Rental 

The agency pays for a rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the agency pays separately for an ear mold(s). 

Cochlear implant – replacement parts

The agency covers: 

Cochlear implant external speech processors, including maintenance, repair, and batteries.

Baha® speech processors, including maintenance, repair, and batteries. 

The agency pays for cochlear implant and Baha® replacement parts when: 

• The manufacturer's warranty has expired. 
• The part is for immediate use, not a back-up part. 
• The part needs to be replaced due to normal wear and tear and is not related to misuse or abuse of the item (see WAC 182-502-0160).

The client must pay for repairs to additional speech processors and parts. 

When reimbursing for battery packs, the agency covers the least costly, equally effective product. 

Note: The agency does not pay providers for repairs or replacements that are covered under the manufacturer’s warranty.

Replacement parts - EPA criteria 

The following expedited prior authorization (EPA) criteria must be met: 

• The cochlear implant or bone conduction (Baha®) is unilateral (bilateral requires PA). 
• The manufacturer’s warranty has expired. 
• The part is for immediate use (not a back-up part). 

Note: If the client does not meet the EPA criteria, then PA is required. 

Use EPA 870000001 with HCPCS codes L8615-L8618, L8621-L8624 when billing for cochlear implant and bone conduction (Baha®) replacement parts