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Member and Recipient Service Line: 1-877-685-2415

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12437 Results

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material;

Service Code
69660 (CPT) Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out

Service Code
69661 (CPT) Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Revision of stapedectomy or stapedotomy

Service Code
69662 (CPT) Revision of stapedectomy or stapedotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair oval window fistula

Service Code
69666 (CPT) Repair oval window fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair round window fistula

Service Code
69667 (CPT) Repair round window fistula
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Mastoid obliteration (separate procedure)

Service Code
69670 (CPT) Mastoid obliteration (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tympanic neurectomy

Service Code
69676 (CPT) Tympanic neurectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Closure postauricular fistula, mastoid (separate procedure)

Service Code
69700 (CPT) Closure postauricular fistula, mastoid (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone

Service Code
69710 (CPT) Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal or repair of electromagnetic bone conduction hearing device in temporal bone

Service Code
69711 (CPT) Removal or repair of electromagnetic bone conduction hearing device in temporal bone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Implantable Bone Conduction Hearing Aids (BAHA)

Service Code
69714 (CPT) Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss who cannot wear a conventional air-conduction hearing aid or cannot reasonably or satisfactorily undergo ossicular replacement surgery. A BAHA device includes the implantation of a titanium abutment to which an external speech processor is attached.

Authorization Guidelines

The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in this policy

Limits

Implantable bone conduction hearing aid devices must be FDA approved for the population being considered.

Exclusions

The BAHA is not covered when:

  • a. the beneficiary has a disease state that may jeopardize osseointegration;
  • b. the beneficiary can gain sufficient benefit from conventional amplification; or
  • c. the beneficiary’s audiometric criteria are outside the range of specifications

Age Group Details

Coverage is limited to beneficiaries 5 through 20 years of age for the implantable device service. Medically necessary maintenance and upgrades of existing internal components for next-generation devices are covered only for beneficiaries ages 5 years and older.

Place of Service

Hospital inpatient, hospital outpatient, ambulatory surgical center. No numeric place of service codes are listed in the policy.

Additional Service Specifics

Implantable bone conduction hearing aid devices shall be FDA approved for the population being considered.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Implantable Bone Conduction Hearing Aids (BAHA)

Service Code
69715 (CPT) Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss who cannot wear a conventional air-conduction hearing aid or cannot reasonably or satisfactorily undergo ossicular replacement surgery. A BAHA device includes the implantation of a titanium abutment to which an external speech processor is attached.

Authorization Guidelines

The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in this policy

Limits

Implantable bone conduction hearing aid devices must be FDA approved for the population being considered.

Exclusions

The BAHA is not covered when:

  • a. the beneficiary has a disease state that may jeopardize osseointegration;
  • b. the beneficiary can gain sufficient benefit from conventional amplification; or
  • c. the beneficiary’s audiometric criteria are outside the range of specifications

Age Group Details

Coverage is limited to beneficiaries 5 through 20 years of age for the implantable device service. Medically necessary maintenance and upgrades of existing internal components for next-generation devices are covered only for beneficiaries ages 5 years and older.

Place of Service

Hospital inpatient, hospital outpatient, ambulatory surgical center. No numeric place of service codes are listed in the policy.

Additional Service Specifics

Implantable bone conduction hearing aid devices shall be FDA approved for the population being considered.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor

Service Code
69716 (CPT) Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Implantable Bone Conduction Hearing Aids (BAHA)

Service Code
69717 (CPT) Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss who cannot wear a conventional air-conduction hearing aid or cannot reasonably or satisfactorily undergo ossicular replacement surgery. A BAHA device includes the implantation of a titanium abutment to which an external speech processor is attached.

Limits

Implantable bone conduction hearing aid devices must be FDA approved for the population being considered.

Exclusions

The BAHA is not covered when:

  • a. the beneficiary has a disease state that may jeopardize osseointegration;
  • b. the beneficiary can gain sufficient benefit from conventional amplification; or
  • c. the beneficiary’s audiometric criteria are outside the range of specifications

Age Group Details

Coverage is limited to beneficiaries 5 through 20 years of age for the implantable device service. Medically necessary maintenance and upgrades of existing internal components for next-generation devices are covered only for beneficiaries ages 5 years and older.

Place of Service

Hospital inpatient, hospital outpatient, ambulatory surgical center. No numeric place of service codes are listed in the policy.

Additional Service Specifics

Implantable bone conduction hearing aid devices shall be FDA approved for the population being considered.

How to Submit

N/A - No authorization is required

Resources

Implantable Bone Conduction Hearing Aids (BAHA)

Service Code
69718 (CPT) Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A bone-anchored hearing aid (BAHA) is a surgically implanted osseointegrated prosthetic device that provides bone conduction hearing for recipients with moderate to severe, bilateral conductive or mixed hearing loss who cannot wear a conventional air-conduction hearing aid or cannot reasonably or satisfactorily undergo ossicular replacement surgery. A BAHA device includes the implantation of a titanium abutment to which an external speech processor is attached.

Authorization Guidelines

The provider(s) shall submit the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in this policy

Limits

Implantable bone conduction hearing aid devices must be FDA approved for the population being considered.

Exclusions

The BAHA is not covered when:

  • a. the beneficiary has a disease state that may jeopardize osseointegration;
  • b. the beneficiary can gain sufficient benefit from conventional amplification; or
  • c. the beneficiary’s audiometric criteria are outside the range of specifications

Age Group Details

Coverage is limited to beneficiaries 5 through 20 years of age for the implantable device service. Medically necessary maintenance and upgrades of existing internal components for next-generation devices are covered only for beneficiaries ages 5 years and older.

Place of Service

Hospital inpatient, hospital outpatient, ambulatory surgical center. No numeric place of service codes are listed in the policy.

Additional Service Specifics

Implantable bone conduction hearing aid devices shall be FDA approved for the population being considered.

How to Submit

Please submit your request to Trillium Health Resources

Resources

Revision or replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor

Service Code
69719 (CPT) Revision or replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Decompression facial nerve, intratemporal; lateral to geniculate ganglion

Service Code
69720 (CPT) Decompression facial nerve, intratemporal; lateral to geniculate ganglion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Decompression facial nerve, intratemporal; including medial to geniculate ganglion

Service Code
69725 (CPT) Decompression facial nerve, intratemporal; including medial to geniculate ganglion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal, osseointegrated implant, skull; with percutaneous attachment to external speech processor

Service Code
69726 (CPT) Removal, osseointegrated implant, skull; with percutaneous attachment to external speech processor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Removal, osseointegrated implant, skull; wwith magnetic transcutaneous attachment to external speech processor

Service Code
69727 (CPT) Removal, osseointegrated implant, skull; wwith magnetic transcutaneous attachment to external speech processor
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required