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

Provider Support Service Line: 1-855-250-1539

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12437 Results

Tympanometry and Acoustic Reflex Testing

Service Code
92550 (CPT) Tympanometry and reflex threshold measurements
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Tympanometry and acoustic reflex testing both provide valuable information when evaluating the middle ear and inner ear respectively. However, each test has its own specific function. Tympanometry provides useful quantitative information about the presence of fluid in the middle ear. This is a useful study for pediatricians, family practitioners, and otolaryngologists as it can be used for determining middle ear disease and, is excellent for following children with a history of middle ear disease. It is the only method of measuring middle ear function in a beneficiary who is unable to perform a formal audiometry test. Tympanometry is usually indicated without acoustic reflex testing. Acoustic reflex testing utilizes sound to test the reflex contractions of the stapedius muscle. This may be measured bilaterally, even when the sound is introduced only on one side. This test is used specifically for the evaluation of sensorineural hearing loss.

Authorization Guidelines

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

Exclusions

Medicaid will not cover the following:

  • a. Tympanometry and acoustic reflex testing for routine screenings.
  • b. Tympanometry and acoustic reflex testing for a beneficiary who does not

meet any of the indications listed in Subsection 3.2.1.

  • c. Tympanometry when any of the following are present:
  • 1. Ear pain;
  • 2. Decreased hearing when no objective hearing test performed;
  • 3. Ear drainage;
  • 4. Fever;
  • 5. Inflamed tympanic membrane;
  • 6. Desquamated epithelium on membrane;
  • 7. Bulging tympanic membrane; or
  • 8. Evidence of middle ear effusion

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and reflex threshold measurements

Service Code
92550 (CPT) Tympanometry and reflex threshold measurements
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92550 (CPT) Tympanometry and reflex threshold measurements
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Screening test, pure tone, air only

Service Code
92551 (CPT) Screening test, pure tone, air only
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Screening test, pure tone, air only

Service Code
92551 (CPT) Screening test, pure tone, air only
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Pure tone audiometry (threshold); air only

Service Code
92552 (CPT) Pure tone audiometry (threshold); air only
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Pure tone audiometry (threshold); air and bone

Service Code
92553 (CPT) Pure tone audiometry (threshold); air and bone
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Speech audiometry threshold;

Service Code
92555 (CPT) Speech audiometry threshold;
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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

Speech audiometry threshold; with speech recognition

Service Code
92556 (CPT) Speech audiometry threshold; with speech recognition
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)

Service Code
92557 (CPT) Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92567 (CPT) Tympanometry (impedance testing)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Tympanometry and acoustic reflex testing both provide valuable information when evaluating the middle ear and inner ear respectively. However, each test has its own specific function. Tympanometry provides useful quantitative information about the presence of fluid in the middle ear. This is a useful study for pediatricians, family practitioners, and otolaryngologists as it can be used for determining middle ear disease and, is excellent for following children with a history of middle ear disease. It is the only method of measuring middle ear function in a beneficiary who is unable to perform a formal audiometry test. Tympanometry is usually indicated without acoustic reflex testing. Acoustic reflex testing utilizes sound to test the reflex contractions of the stapedius muscle. This may be measured bilaterally, even when the sound is introduced only on one side. This test is used specifically for the evaluation of sensorineural hearing loss.

Authorization Guidelines

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

Exclusions

Medicaid will not cover the following:

  • a. Tympanometry and acoustic reflex testing for routine screenings.
  • b. Tympanometry and acoustic reflex testing for a beneficiary who does not

meet any of the indications listed in Subsection 3.2.1.

  • c. Tympanometry when any of the following are present:
  • 1. Ear pain;
  • 2. Decreased hearing when no objective hearing test performed;
  • 3. Ear drainage;
  • 4. Fever;
  • 5. Inflamed tympanic membrane;
  • 6. Desquamated epithelium on membrane;
  • 7. Bulging tympanic membrane; or
  • 8. Evidence of middle ear effusion

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry (impedance testing)

Service Code
92567 (CPT) Tympanometry (impedance testing)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92567 (CPT) Tympanometry (impedance testing)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92568 (CPT) Acoustic reflex testing, threshold
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Tympanometry and acoustic reflex testing both provide valuable information when evaluating the middle ear and inner ear respectively. However, each test has its own specific function. Tympanometry provides useful quantitative information about the presence of fluid in the middle ear. This is a useful study for pediatricians, family practitioners, and otolaryngologists as it can be used for determining middle ear disease and, is excellent for following children with a history of middle ear disease. It is the only method of measuring middle ear function in a beneficiary who is unable to perform a formal audiometry test. Tympanometry is usually indicated without acoustic reflex testing. Acoustic reflex testing utilizes sound to test the reflex contractions of the stapedius muscle. This may be measured bilaterally, even when the sound is introduced only on one side. This test is used specifically for the evaluation of sensorineural hearing loss.

Authorization Guidelines

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

Exclusions

Medicaid will not cover the following:

  • a. Tympanometry and acoustic reflex testing for routine screenings.
  • b. Tympanometry and acoustic reflex testing for a beneficiary who does not

meet any of the indications listed in Subsection 3.2.1.

  • c. Tympanometry when any of the following are present:
  • 1. Ear pain;
  • 2. Decreased hearing when no objective hearing test performed;
  • 3. Ear drainage;
  • 4. Fever;
  • 5. Inflamed tympanic membrane;
  • 6. Desquamated epithelium on membrane;
  • 7. Bulging tympanic membrane; or
  • 8. Evidence of middle ear effusion

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Acoustic reflex testing, threshold

Service Code
92568 (CPT) Acoustic reflex testing, threshold
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92568 (CPT) Acoustic reflex testing, threshold
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92570 (CPT) Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Tympanometry and acoustic reflex testing both provide valuable information when evaluating the middle ear and inner ear respectively. However, each test has its own specific function. Tympanometry provides useful quantitative information about the presence of fluid in the middle ear. This is a useful study for pediatricians, family practitioners, and otolaryngologists as it can be used for determining middle ear disease and, is excellent for following children with a history of middle ear disease. It is the only method of measuring middle ear function in a beneficiary who is unable to perform a formal audiometry test. Tympanometry is usually indicated without acoustic reflex testing. Acoustic reflex testing utilizes sound to test the reflex contractions of the stapedius muscle. This may be measured bilaterally, even when the sound is introduced only on one side. This test is used specifically for the evaluation of sensorineural hearing loss.

Authorization Guidelines

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

Exclusions

Medicaid will not cover the following:

  • a. Tympanometry and acoustic reflex testing for routine screenings.
  • b. Tympanometry and acoustic reflex testing for a beneficiary who does not

meet any of the indications listed in Subsection 3.2.1.

  • c. Tympanometry when any of the following are present:
  • 1. Ear pain;
  • 2. Decreased hearing when no objective hearing test performed;
  • 3. Ear drainage;
  • 4. Fever;
  • 5. Inflamed tympanic membrane;
  • 6. Desquamated epithelium on membrane;
  • 7. Bulging tympanic membrane; or
  • 8. Evidence of middle ear effusion

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing

Service Code
92570 (CPT) Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Trillium Health Resources

Resources

Tympanometry and Acoustic Reflex Testing

Service Code
92570 (CPT) Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Place of Service

Inpatient, Outpatient, Office

How to Submit

Please submit your request to Trillium Health Resources

Resources

Filtered speech test

Service Code
92571 (CPT) Filtered speech test
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Unit Value

1 unit =1 event

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources