At the start of 2024, a prior authorization requirement was added to the Federal Employee Program (FEP) Blue Cross Blue Shield (BCBS) coverage requirements for prescription hearing aids for the Basic Option and Standard Plans. The updated FEP coverage guidance for beneficiaries now notes that hearing aids without prior approval will not be covered in post-service review. Only prescription hearing aids are addressed in this new guideline.
Over-the-counter (OTC) class hearing aids (U.S. Food and Drug Administration (FDA), 2023) are not covered under the Basic Option and Standard Option Plan benefit. Medical necessity is defined as hearing loss confirmed by audiometry or other age-appropriate testing (completed in the six months prior to hearing aid purchase) to be greater than 26 dB hearing loss for conductive, sensorineural, or mixed. At the start of January 2024, the requisite degree of hearing loss was 40 dB or greater. This was amended as per the most recent BCBS guidance document effective April 1, 2024, to reflect the current 26 dB or greater loss.
Medical Necessity Considerations for New Prescription Hearing Aids
- Hearing aids must be approved, listed, and/or registered with the FDA as a prescription device.
- Hearing aids dispensed by prescription or signed written order from a licensed health-care provider practicing within the scope of their license.
- Prescription should include the make/model of the recommended hearing aid.
- Audiometric testing should be completed no longer than six months prior to hearing aid purchase.
- Degree of hearing loss greater than 26 dB hearing loss for conductive, sensorineural, or mixed hearing loss.
Documentation to Assist in Substantiating Medical Necessity
- Prescription hearing aid will serve a purpose in treating this medical issue.
- Hearing aid recommendation is consistent with standards of practice for this medical issue.
- Prescription hearing aid is clinically appropriate and effective for the medical issue (e.g., type, degree, site of lesion, duration).
- Prescription hearing aid is not a convenience item.
Documentation of Medical Necessity for Hearing Aid Replacements (Dispensed within >3 or <5)
Replacement in addition to documenting the medical necessity considerations for new hearing aids, providers must also document the following:
- History of hearing aid use.
- Use of prior treatments to address hearing loss symptoms.
- Description of hearing loss status as it relates to function.
- Date of testing, types of testing performed in comprehensive audiometric evaluation, and test results.
- Demonstration of need for replacement hearing aid; notes on how current device in inadequately functioning, damaged beyond repair and out of warranty.
- If applicable, notation of significant changes in hearing that necessitate use of different hearing aids. Significant change is defined as 15 dB shift at one or more frequencies between 0.5 and 4kHz.
- Recommendation for the replacement device(s) type.
- Plan for assessing effectiveness and outcomes with replacement device.
- Notations of trial period and warranty.
Not Covered
- Over-the-counter hearing aids, hearing assistive devices, and personal sound amplification products (PSAPs).
- Accessories for convenience and not medically necessary such as streamer remote/TV adapter, phone clip, remote control, remote microphone, apps.
- Hearing aids returned for a refund during trial period.
- Repair of hearing aid performed under warranty.
- Repair or replacement due to loss, misuse, or abuse.
How to Submit for Prior Approval?
The process to obtain prior authorization is variable from state to state as BCBSA has indicated they are not able to dictate a uniform process across all plans. Providers should check with their local BCBS or the FEP utilization management department for their preferred and/or required forms.
Additionally, pre-authorizations may be obtained through the Availity website and/or by faxing the pre-authorization form and supporting documentation to BCBS FEP or local BCBS as indicated. With the prior authorization form, you should include: (1) audiological report, (2) letter of medical necessity, (3) prescription for specific make/model of the recommended hearing prescription hearing aids, and (4) copy of relevant office visit notes in support of medical necessity.
