Bone Conduction Implants
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Bone anchored hearing devices (BAHA), unilateral or bilateral, full or partial, indicated for conductive, mixed hearing loss, or unilateral deafness hearing loss may be considered medically necessary as prosthetic devices when at least
ONE
of the following criteria are met:
-
Congenital or surgically induced malformation (e.g., atresia) of the external ear, ear canal, or middle ear,
or
-
Infection of the ear canal resulting in chronic draining ears,
or
-
Fixation of the ossicles (middle ear bones),
or
-
Single sided deafness (SSD) (allow stimulation of the functioning cochlea) due to:
-
Viral infections (CMV, HSV, Measles, or others);
or
-
Meniere's Disease;
or
-
Trauma;
or
-
Sudden deafness;
or
-
Acoustic neuroma;
or
-
Individual who is indicated for an air conduction contralateral routing of signals (AC CROS) hearing aid, but who for some reason cannot or will not use an AC CROS;
or
-
Individuals who cannot wear conventional hearing aids for
ONE
or the following reasons:
-
Tumors of the ear canal or tympanic cavity;
or
-
Dermatitis of the external ear canal;
or
-
Severe chronic otitis or otitis media;
or
- Sensitivity to ear molds.
There
MUST
be a functioning cochlea or cranial nerve VIII for the BAHA to work and
ALL
the following audiological criteria must be met:
- Individual age five (5) or older;
- A pure tone average (PTA) bone-conduction threshold measured at 0.5, 1, 2, and 3 kHz of better than or equal to 45 dB (OBC and BP100 devices), 55 dB (Intenso device) or 65 dB (Cordele II device).
- As an alternative to an air-conduction CROS hearing aid in individuals five (5) years of age and older with single-sided sensorineural deafness and normal hearing in the other ear; and the pure tone average air conduction threshold of the normal ear should be better than 20 dB measured at 0.5, 1, 2, and 3 kHz.
For bilateral implantation, individuals should meet the above audiologic criteria, and have a symmetrically conductive or mixed hearing loss as defined by a difference between left and right side bone conduction threshold of less than 10 dB on average measured at 0.5, 1, 2 and 3 kHz, or less than 15 dB at individual frequencies.
One (1) headband per year may be considered medically necessary. More than one (1) headband per year will be denied as not medically necessary.
Processor replacement may be considered medically necessary two (2) per five (5) years. Processor replacement greater than two (2) per five (5) years will be denied as not medically necessary.
Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.
BAHA not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
| 69710 | 69711 | 69714 | 69716 | 69717 | 69719 | 69726 |
| 69727 | 69728 | 69729 | 69730 | L8618 | L8624 | L8625 |
| L8690 | L8691 | L8692 | L8693 | L8694 | L8699 | S2230 |
| V5095 |
