Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1.     This policy applies only to those QualChoice plans that provide coverage for hearing aids. (Refer to the appropriate plan document or rider).Coverage is limited to $1,400.00 per ear or $2,800 for both ears.

2.     Coverage is only available when the aid is dispensed by an Arkansas licensed hearing aid supplier.

3.     The benefits applied may be subject to the plan co-insurance rates. (Refer to the appropriate plan document).

4.     This benefit includes the repair and fitting of the hearing aids.

5.     Hearing testing is covered under the medical benefit.

6.     Requests for hearing aids more often than every 3 years require pre-authorization to verify medical necessity.

Cochlear Implants (BI185) are addressed in a separate policy.

Bone Anchored Hearing Aids (BI289) is addressed in a separate policy.

1.    This policy applies only to those QualChoice plans that provide coverage for hearing aids. Please refer to the appropriate plan document.

2.    For FEHBP coverage policy, see BI264.

3.    Coverage is limited to $1,400 per ear or $2,800 for both ears.

4.    Pre-authorization is required to ensure medical necessity if hearing aid has previously been requested within last 3 years.

5.    Coverage is only available when the aid is dispensed by an Arkansas licensed hearing aid supplier.

6.    The benefits applied will be subject to the plan co-insurance rates.

7.    This benefit includes the repair and fitting of the hearing aids.

8.    Hearing testing is covered under the medical benefit.

9.    Cochlear implants as a treatment for deafness are covered subject to being included in the coverage documents of the plan. Please see BI185: Cochlear Implants for coverage criteria.

10.   Coverage criteria for bone anchored hearing aids can be found in BI289: Bone Anchored Hearing Aids.

11.   Tests provided to determine hearing acuity are covered when medically necessary. Medical necessity is presumed in all such cases.

Codes Used In This BI:

V5230    Hearing aid, contralateral routing system, binaural, glasses code revised 1/1/19

V5240    Dispensing fee, contralateral routing system, binaural code revised 1/1/19

V5241    Dispensing fee, monaural hearing aid, any type

V5242    Hearing aid, analog, monaural, CIC (completely in the ear canal)

V5243    Hearing aid, analog, monaural, ITC (in the canal)

V5244    Hearing aid, digitally programmable, analog, monaural, CIC

V5245    Hearing aid, digitally programmable, analog, monaural, ITC

V5246    Hearing aid, digitally programmable, analog, monaural, ITE (in the ear)

V5247    Hearing aid, digitally programmable, analog, monaural, BTE (behind the ear)

V5248    Hearing aid, analog, binaural, CIC

V5249    Hearing aid, analog, binaural, ITC

V5250    Hearing aid, digitally programmable analog, binaural, CIC

V5251    Hearing aid, digitally programmable analog, binaural, ITC

V5252    Hearing aid, digitally programmable, binaural, ITE

V5253    Hearing aid, digitally programmable, binaural, BTE

V5254    Hearing aid, digital, monaural, CIC

V5255    Hearing aid, digital, monaural, ITC

V5256    Hearing aid, digital, monaural, ITE

V5257    Hearing aid, digital, monaural, BTE

V5258    Hearing aid, digital, binaural, CIC

V5259    Hearing aid, digital, binaural, ITC

V5260    Hearing aid, digital, binaural, ITE

V5261    Hearing aid, digital, binaural, BTE

V5262    Hearing aid, disposable, any type, monaural

V5263    Hearing aid, disposable, any type, binaural

V5264    Ear mold/insert, not disposable, any type

V5265    Ear mold/insert, disposable, any type

V5266    Battery for use in hearing device

V5267    Hearing aid or assistv listening dvc/supp/access, NOS

V5268    Assistv listen dvc, telephone amplifier, any type

V5269    Assistv listen dvc, alerting, any type

V5270    Assistv listen dvc, television amplifier, any type

V5271    Assistv listen dvc, television caption decoder

V5272    Assistv listen dvc, TDD

V5273    Assistv listen dvc, for use with cochlear implant

V5274    Assistv listen dvc, NOS

V5275    Ear impression, each

V5281    Assistv listen dvc, persnl FM/DM syst, monaural (1 recvr, trnsmttr, micrphn), any type

V5282    Assistv listen dvc, persnl FM/DM syst, binaural (2 recvr, trnsmttr, micrphn), any type

V5283    Assistv listen dvc, persnl FM/DM neck, loop induction recvr

V5284    Assistv listen dvc, persnl FM/DM, ear level recvr

V5285    Assistv listen dvc, persnl FM/DM, direct audio input recvr

V5286    Assistv listen dvc, persnl blue tooth FM/DM recvr

V5287    Assistv listen dvc, persnl FM/DM recvr, NOS

V5288    Assistv listen dvc, persnl FM/DM transmitter assistv listen dvc

V5289    Assistv listen dvc, persnl FM/DM adapter/boot coupling dvc for any recvr, any type

V5290    Assistv listen dvc, transmitter microphone, any type

V5298    Hearing aid, not otherwise classified

Addendum:

Effective 01/01/2018: Removed technology restrictions to more closely match AR benchmark plan.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.