Differentiation Through a 21st Century Audiologic Evaluation Model
Following considerable advocacy from members and all stakeholders in the audiology and hearing aid dispensing communities, including but not limited to the representatives of the Academy of Doctors of Audiology (ADA), the Blue Cross/Blue Shield Federal Employee Plan (FEP) has updated its utilization management guidelines for hearing aids, effective April 1, 2024. We strongly encourage all members and their staffs to thoroughly read and review these updated guidelines themselves, which can be found at https://www.fepblue.org/-/media/ PDFs/Medical-Policies/2024/March/Mar-2024-Medical-Policies/Remove---Replace/FEP-UM-Guideline- 005-Hearing-Aids-2024-benefit.pdf.
The changes and chief considerations for audiologists in the updated guidelines are as follows:
BCBS FEP requires prior authorization for all hearing aids.
Medical Necessity Requirements for Hearing Aids (initial or replacement)
- “Must be approved, listed, and/or registered with the FDA as a prescription device,
- Dispensed by prescription or signed written order from a licensed healthcare provider who is practicing within the scope of their license. a. Hearing aid purchase within 6 months of the date of prescription,
- Hearing loss determined and documented by audiometric testing (hearing test) completed in the 6 months prior to hearing aid purchase,
- The degree of hearing loss is confirmed by audiometry or other age-appropriate testing to be greater than 26 dB hearing loss (HL) for: a. conductive hearing loss unresponsive to medical or surgical interventions b. sensorineural hearing loss c. mixed hearing loss (combination of conduction hearing loss and sensorineural hearing loss)”
Medical Necessity Requirement for Replacement Hearing Aids
- “Member’s past history of hearing aid use
- Pertinent medical history, description of functional status, relevant prior treatment
- Comprehensive audiometric testing: date, type of testing and results that demonstrates the hearing loss and need for a replacement hearing aid.
- The currently used device is no longer functioning adequately and has been determined to be non-repairable and is not under warranty, OR
- Significant change in the person’s hearing that requires a different hearing aid (at least a 15 dB change in at least one frequency between 500 and 4000 Hz)
- Recommendation for type of replacement device
- Follow-up plan for assessing effectiveness/outcome of use of the replacement hearing aid, including trial period and warranty information.”
Definition of Medical Necessity
“Medical necessity shall mean healthcare services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
- In accordance with generally accepted standards of medical practice in the United States; and
- Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and
- Not primarily for the convenience of the patient, physician, or other healthcare provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and
- Not part of or associated with scholastic education or vocational training of the patient; and
- In the case of inpatient care, able to be provided safely only in the inpatient setting.
Not Medically Necessary
- Accessories which are for convenience and not medically necessary (such as streamers, TV adaptors, phone clip, remote controls, remote microphones, and apps).
- Hearing aids that have been returned for a refund during the trial/adjustment period.
- Repair of hearing aid performed under warranty.
- Repair or replacement of hearing aids due to loss, misuse, or abuse.
- Over-the-counter hearing aids/ hearing assistive devices/ personal sound amplification products (PSAPs) available without a prescription.
Recommendations
- Follow the utilization management guidance (https://www.fepblue.org/-/media/PDFs/Medical-Policies/2024/March/Mar-2024-Medical-Policies/Remove---Replace/FEP-UM-Guideline-005-Hearing-Aids-2024-benefit.pdf)
- For initiating the prior authorization process, use your Availity or BCBS portal, the pre-certification contact phone number and/or fax number for your state FEP plan, or have your office or the FEP member contact the number on their insurance card.
- Documentation: Based upon the medical necessity guidance, it is important to document, in the medical record, the medical necessity of the make, model, type, style, and features of the hearing aid for each specific patient. FEP covers what is minimally medically necessary.
- For prior authorization requests, you must include the results of a comprehensive audiogram (air conduction, bone conduction, speech reception threshold, and speech discrimination) performed in the past six months.
- For appeals, request a “like specialty review” and clearly document medical necessity as outlined above.
Please do not hesitate to contact Kim Cavitt at