Bone Conduction Implants
Unilateral or bilateral fully or partial implantable Bone Anchored Hearing Devices (BAHA), may be considered medically necessary as prosthetic devices when the following indications and criteria are met:
The BAHA is indicated for conductive, mixed hearing loss or unilateral deafness hearing loss. This includes at least
ONE
of the following:
-
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) due to: (allow stimulation of the functioning cochlea)
-
Viral infections (CMV, HSV, Measles, or others);
or
-
Meniere's Disease;
or
-
Trauma;
or
-
Sudden deafness;
or
- Acoustic Neuroma.
-
There must be a functioning cochlea or cranial nerve VIII for the BAHA to work;
and
-
The following audiologic 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.
- BAHA for SSD is also indicated for any 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
BAHA may also be consider medically necessary for the individuals who cannot wear conventional hearing aids due to tumors of the external canal and/or tympanic cavity; or dermatitis of the external canal; or severe chronic external otitis or otitis media, or hypersensitivity reactions to earmolds.
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.
Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.
BAHA for any other indication than listed above is considered not medically necessary.
Procedure Codes
| 61520 | 61530 | 61598 | 69714 | 69716 | 69719 | 69726 |
| 69727 | 69729 | 69730 | L8690 | L8692 | L8693 | L8699 |
| S2230 | V5095 |
