For Prior Authorization Requests Received Before July 1, 2015

Implant and Non-implant Bone-Anchored Hearing Aids

ForwardHealth has developed PA approval criteria for unilateral bone-anchored hearing aid implant surgeries, bilateral bone-anchored hearing aid implant surgeries, bone-anchored hearing aid implant surgeries for profound unilateral sensorineural hearing loss with normal hearing in the opposite ear, and for bone-anchored hearing aids that do not require surgery.

When submitting a PA request for bone-anchored hearing aid implant surgery, the rendering surgeon is required to submit the following:

• PA/RF.
• PA/PA.
• PA/HIAS2.

Approval Criteria for Unilateral Bone-Anchored Hearing Aid Implant Surgeries

The following criteria must be met for PA requests to be approved for unilateral bone-anchored hearing aid implant surgeries:

• The member is 5 years of age or older at the time of surgery.
• The member has sufficient bone volume and bone quality to support successful fixture placement as determined by the surgeon AND the surgeon determines that the implant can safely be done in a one-step procedure.
• The member has a conductive and/or mixed hearing loss (unilateral or bilateral) with pure-tone average bone-conduction thresholds (measured at 0.5, 1, 2, and 3 kHz) less than or equal to 65 dB HL. The threshold range is intended to accommodate different degrees of hearing loss and corresponding output power of the bone-anchored hearing aid unit.
• The member demonstrates an air-bone gap of at least 30 dB in the proposed implant ear.
• The member demonstrates a word recognition score greater than 60% via conventional air-conduction speech audiometry using single-syllable words.
• The member has one or more of the following conditions:
• Severe chronic external otitis or otitis media.
• Chronic draining ear through a tympanic membrane perforation.
• Malformation of the external auditory canal or middle ear.
• Stenosis of the external auditory canal.
• Ossicular discontinuity or erosion that cannot be repaired.
• Chronic dermatologic conditions such as psoriasis of the ear canal.
• Tumors of the external canal and/or tympanic cavity.
• Other conditions in which an air-conduction hearing aid is contraindicated for the ear to be implanted, or where the condition prevents restoration of hearing using a conventional air-conduction hearing aid.

Approval Criteria for Bilateral Bone-Anchored Hearing Aid Implant Surgeries

The following criteria must be met for PA requests to be approved for bilateral bone-anchored hearing aid implant surgeries:

• The member meets the unilateral bone-anchored hearing aid criteria noted above for both ears and has symmetrical bone-conduction thresholds between ears. Symmetrical bone-conduction thresholds are defined as less than a 10 dB average difference between ears (measured at 0.5, 1, 2, and 3 kHz), or less than a 15 dB difference at individual frequencies.
• The member presents lifestyle needs that justify the need for binaural hearing via bone conduction.

Approval Criteria for Bone-Anchored Hearing Aid Implant Surgeries for Profound Unilateral Sensorineural Hearing Loss with Normal Hearing in the Opposite Ear

Profound unilateral sensorineural hearing loss with normal hearing in the opposite ear is sometimes referred to as unilateral sensorineural deafness or single-sided deafness (SSD).

The following criteria must be met for PA requests to be approved for bone-anchored hearing aid implant surgeries for profound unilateral sensorineural hearing loss:

• The member has normal hearing in one ear, defined as a pure-tone average air-conduction threshold measured at 0.5, 1, 2, and 3 kHz of 20 dB HL or better.
• The member has average air-conduction thresholds measured at 0.5, 1, 2, and 3 kHz in the ear with the sensorineural hearing loss of 90 dB HL or poorer.
• The member is 5 years of age or older at the time of surgery.
• The member has sufficient bone volume and bone quality to support successful fixture placement as determined by the surgeon AND the surgeon determines that the implant can safely be done in a one-step procedure.
• The member is mature enough and otherwise able to give accurate feedback on the effectiveness of the intervention during a trial period.

Approval Criteria for Bone-Anchored Hearing Devices That Do Not Require Surgery

Bone-anchored hearing aids that use a processor and headband (rather than a surgically implanted device) require PA. When submitting a PA request for bone-anchored hearing devices that use a processor and headband, providers are required to submit the PA/HIAS1 and PA/HIAS2.

Approval for a bone-anchored hearing device that uses a processor and headband requires that the provider adhere to all PA criteria for a unilateral bone-anchored hearing device with the exception of the surgically related criteria. The ear receiving the bone-conduction device must be specified.