Evaluation of Hearing Impairment/Loss Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 02|01|2025 POLICY LAST REVIEWED: 03|05|2025 OVERVIEW Audiology is a specialty focusing on hearing impairment/loss through identification and evaluation, and the rehabilitation of persons with hearing impairment/loss. Audiological services are normally provided by a licensed audiologist who performs audiometric/diagnostic tests that evaluate both sensorineural and conductive hearing impairment/losses.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable
POLICY STATEMENT Medicare Advantage Plans and Commercial Products Evaluation of hearing impairment tests are considered medically necessary in illnesses or injuries including, but not limited to, the following: Hearing loss; Otitis media; Meniere’s disease; Labyrinthitis; Vertigo (dizziness); Tinnitus; Cochlear otosclerosis; Neoplasms of the auditory or central nervous system; Congenital anomalies; Surgery involving the auditory and/or central nervous system, e.g., skull-based tumors such as acoustic neuroma and meningioma; Facial nerve paralysis (Bell’s palsy); Bacterial meningitis; Exposure to intense noise; Ototoxic drugs; Fractures of the temporal bone or trauma affecting the central auditory pathways. Hearing exams and diagnostic hearing tests are covered when furnished by a physician, audiologist or other qualified provider. Audiology studies performed by independently licensed audiologists are covered diagnostic services when they are ordered by a physician or an Advance Practice Provider. The following audiometric tests are considered obsolete and thus are not covered for Medicare Advantage Plans and not medically necessary for Commercial products: • Lombard test (replaced by the Stenger test and auditory evoked potential); • Alternate binaural loudness balance test; • Short increment sensitivity test (replaced by pure tone audiometry, auditory evoked potential); • Bekesy audiometry. The following audiometric tests are not covered for Medicare Advantage Plans and not medically necessary for Commercial products as there is no scientific literature to support efficacy:
• Staggered spondaic word test; • Synthetic sentence identification test. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits for Hearing Services.
BACKGROUND Medical Coverage Policy | Evaluation of Hearing Impairment/Loss

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Hearing impairment or hearing loss is a reduction in the ability to perceive sound. The loss may range from slight to complete deafness caused by sensorineural and/or conductive hearing losses.

Audiology is a specialty focusing on hearing impairment or hearing loss through identification and evaluation, and the rehabilitation of persons with hearing impairment or hearing loss. Audiological services are normally provided by a licensed audiologist who performs audiometric/diagnostic tests that evaluate both sensorineural and conductive hearing impairment/losses.

The various audiometric tests can be subdivided into standard batteries that are typically used as part of the initial work-up of patients presenting with hearing impairment, as well as specialized tests that are typically used in specific clinical situations. The standard batteries vary according to whether the patient is an adult, child, or infant. Tests identified as specialized would not be part of the initial hearing impairment work-up, but may be considered medically necessary when initial diagnostic tests are inconclusive or not appropriate to the specific condition.

The following tests identify standard and specialized audiology tests for adults, children, and infants:

Standard Battery of Tests

For Adults and Children:

1. Pure-tone audiometry, air and bone conduction
2. Speech audiometry
3. Word recognition tests
4. Acoustic reflex test and acoustic reflex decay

5. Tympanometry (impedance testing)

   For Children Only:

6. Select picture audiometry

7. Conditioning play audiometry

   For Infants Only:

8. Auditory evoked potential, aka Auditory Brainstem Response (ABR)
9. Visual reinforcement audiometry (VRA)
10. Evoked otoacoustic emissions (OAE)

11. Acoustic reflex test

    Specialized Tests for Adults and Children:

12. Auditory Evoked Potential
13. Electrocochleography (ECochG)
14. Tone decay test
15. Stenger test, pure tone or speech
16. Sensorineural acuity level (SAL) test

17. Evoked otoacoustic emissions

    CODING Medicare Advantage Plans and Commercial Products The following tests are covered:

    Hearing Tests (routine): 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

V5008 Hearing screening

Hearing Tests: 92550 Tympanometry and reflex threshold measurements 92553 Pure tone audiometry (threshold); air and bone 92555 Speech audiometry threshold; 92556 Speech audiometry threshold; with speech recognition 92563 Tone decay test 92565 Stenger test, pure tone 92567 Tympanometry (impedance testing) 92568 Acoustic reflex testing; threshold 92570 Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex

         threshold testing, and acoustic reflex decay testing

92571 Filtered speech test 92575 Sensorineural acuity level test 92577 Stenger test, speech 92579 Visual reinforcement audiometry (VRA) 92582 Conditioning play audiometry 92583 Select picture audiometry 92584 Electrocochleography 92587 Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence

         or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions,  
         with interpretation and report

92588 Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation

         (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12  
         frequencies), with interpretation and report

92650 Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated

         analysis

92651 Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report
92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report

The following codes are not covered for Medicare Advantage Plans and not medically necessary for Commercial products:
92562 Loudness balance test, alternate binaural or monaural 92572 Staggered spondaic word test 92576 Synthetic sentence identification test

RELATED POLICIES Hearing Aid Mandate
Preventive Services for Commercial Members

PUBLISHED Provider Update, May 2025 Provider Update, March/December 2024 Provider Update, April 2023 Provider Update, June 2022 Provider Update, May 2021

REFERENCES

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

1. American Academy of Pediatrics. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000; 106(4):798-817.
2. Bamiou DE, Musiek FE, Luxon LM. Aetiology and clinical presentations of auditory processing disorders – a review. Arch Dis Child 2001; 85(5):361-5.
3. Amos NE, Humes LE. SCAN test-retest reliability for first and third grade children. J Speech Lang Hear Res 1998; 41(4):834-45.
4. Domitz DM, Schow RL. A new CAPD battery – multiple processing assessment: factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2):101-11.
5. Task Force on Central Auditory Processing Consensus Development. American Speech-Language- Hearing Association. Central auditory processing: Current status of research and implications for clinical practice. Am J Audiol 1996; 5:41-54.

6. Jerger J, Musiek F. Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000; 11(9):467-74.

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS