01Already effective April 16, 2026: Coverage for implantable bone conduction hearing aids is provided under the member's prosthetic benefit, so bill these services under that benefit only when the policy criteria are met.
02For a new device, confirm the member is five years of age or older, has conductive or mixed hearing loss, has speech discrimination scores of at least 60% at elevated sound pressure levels, has a bone-conduction pure-tone average up to 70 dB in the affected ear, and has one of the listed ear conditions (congenital or surgical malformation of the ear canal or middle ear, chronic external otitis or otitis media, or other acquired malformation that precludes a conventional air conduction hearing aid).
03Single-sided sensorineural deafness with normal hearing in the other ear is handled under the separate CROS criteria in the policy.
04For repair of a device or component not under warranty, the physician documentation must include the date of implantation or initiation, manufacturer warranty information if applicable, and an attestation that the patient has been compliant with use and will continue to benefit.
05The device must no longer be functioning adequately, the inadequate function must interfere with activities of daily living, and repair must be expected to make the equipment fully functional as defined by the manufacturer.
06Repair is ineligible for equipment damaged from patient neglect, theft or abuse, or when another coverage source such as homeowners, rental, auto or liability insurance is an option.
07For replacement, document either that the device is no longer functioning adequately and is non-repairable or that repair costs exceed replacement cost, or that a change in the patient's condition makes the unit nonfunctional and improvement is expected with a replacement unit.
08Replacement of a properly functioning device, including replacement for more advanced technology or a more aesthetic appearance, is not medically necessary.
09Accessories or components that peer-reviewed literature considers not medically necessary or investigational are also not medically necessary.
10Other uses, such as bilateral sensorineural hearing loss, are investigational.
11The policy notes that codes may not be covered under all circumstances.