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Hearing Aid Services

Service Code
V5299 (HCPCS) Hearing service, miscellaneous
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

The NC Medicaid (Medicaid) programs provide hearing aids, FM systems, hearing aid accessories and supplies, and dispensing fees when there is medical necessity. Note: This policy does not address cochlear or auditory brainstem implant coverage. For eligible beneficiaries with profound hearing impairment requiring cochlear or auditory brainstem implantation, refer to clinical coverage policy 1A-4, Cochlear and Auditory Brainstem Implants.

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

Limits

The beneficiary shall receive a medical examination from a physician (including otologist, otolaryngologist and otorhinolaryngologist) and documentation of medical clearance for the initiation of the hearing aid selection process. Covered only for beneficiaries under 21 years of age under Medicaid.

A current medical clearance must be based on a medical evaluation within the preceding six months.

The beneficiary must be given a 30 calendar-day trial period before the post-dispensing evaluation.

The dispensing claim can only be billed after the post-dispensing evaluation, which should generally occur within 30 days after dispensing.

The new hearing aid dispense includes at least one year of service and regular maintenance at no extra cost.

The initial month supply of batteries is included and cannot be billed separately. Replacement requests are subject to review of the frequency of other replacements.

If the replacement aid is under the manufacturer's warranty and loss and damage policy, a dispensing fee cannot be billed when the manufacturer pays a dispensing fee to the provider for the replacement.ill one unit per battery claim.

Reimbursement is limited to up to $35 per battery claim.

Up to six battery claims per year do not require prior approval; additional battery claims require prior approval.

The initial one-month supply of batteries furnished with a new hearing aid cannot be billed separately. Medicaid does not cover hearing aid services, including FM systems, for beneficiaries 21 years of age and older.

FM systems for educational purposes are expected to be provided by public school systems starting at age three under IDEA; Medicaid consideration is for FM systems not covered through IDEA.

Claims for a new FM system must be accompanied by an invoice.

  • • Ear mold claims must be accompanied by an invoice.
  • • Accessory claims must be accompanied by an invoice or invoices.
  • • For accessory claims with multiple invoices, bill one unit with the combined invoice total and one dispensing fee.
  • • An ear mold dispensing fee cannot be billed on a new hearing aid claim.
  • • A separate dispensing fee cannot be billed for ear molds or accessories that are components of new hearing aids

Exclusions

Non-covered hearing aid products and services include:

  • a. battery charger or tester
  • b. adapter for telephone, television, or radio
  • c. shipping, handling, postage, or insurance fee
  • d. loss and damage insurance
  • e. in-the-ear hearing aid that is requested for primarily cosmetic purpose
  • f. extended warranty policy

This list is not all inclusive. Replacement hearing aid requests may be denied when loss or damage is due to improper care or negligence, because improper care or negligence does not constitute extenuating circumstances. Prior approval is not required for up to six battery claims per year, with a maximum of $35 per claim. If additional batteries are needed beyond six claims per year, the provider shall submit an electronic prior approval request with documentation of medical necessity. Each such request is reviewed on a case-by-case basis. Batteries supplied as the initial one-month supply with a new hearing aid are not separately billable because they are included as a component of the new hearing aid dispense.FM systems used for educational purposes that are covered by public school systems under IDEA are not the Medicaid-covered scenario addressed for FM system prior approval; Medicaid consideration is for FM systems not covered through IDEA.

Diagnosis Requirements

Covered hearing aid products and services include hearing aids and dispensing fees. Newly fit binaural hearing aids require a medical examination and medical clearance from a physician to initiate the hearing aid selection process, plus a hearing evaluation by a licensed audiologist including an audiogram. The prior approval package for new hearing aids must include the initial hearing evaluation, audiogram, hearing aid selection results, and written evaluation. If the devices requested are digital programmable hearing aids, the prior approval request must also include documentation of medical necessity.

Age Group Details

Medicaid shall not cover Hearing Aid Services for beneficiaries 21 years of age and older

Place of Service

Inpatient hospital (21), outpatient hospital (22), comprehensive outpatient rehabilitation facility (62), office (11), state or local public health clinics (71), rural health clinics (72), and home (12).

Additional Service Specifics

The provider shall obtain prior approval by submitting an electronic prior approval request at http://www.nctracks.nc.gov for all hearing aids, FM systems, care kits, repairs,accessories, custom ear molds, replacement parts, batteries in excess of six claims per year with a maximum of $35 per claim, and dispensing fees.

Prior approval requests for hearing aids must include the hearing aid manufacturer’s name, model name or number, style (body, BTE, etc.), type (analog or digital programmable, etc.) and the estimated invoice cost

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

V5336 Communication Device-Repairs

Service Code
V5336 (HCPCS) V5336 Communication Device-Repairs
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Speech screening

Service Code
V5362 (HCPCS) Speech screening
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Language screening

Service Code
V5363 (HCPCS) Language screening
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Dysphagia screening

Service Code
V5364 (HCPCS) Dysphagia screening
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

CO2 saturation monitor with accessories, probes

Service Code
W4001 (HCPCS) CO2 saturation monitor with accessories, probes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Manual Ventilation Bag (e.g., an Ambu bag)

Service Code
W4002 (HCPCS) Manual Ventilation Bag (e.g., an Ambu bag)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Unlisted replacement or repair parts

Service Code
W4005 (HCPCS) Unlisted replacement or repair parts
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Bath seat, pediatric (e.g., TLC)

Service Code
W4016 (HCPCS) Bath seat, pediatric (e.g., TLC)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Miscellaneous for DME

Service Code
W4047 (HCPCS) Miscellaneous for DME
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Wheelchair seat width, greater than 27"

Service Code
W4117 (HCPCS) Wheelchair seat width, greater than 27"
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Wheelchair seat depth, greater than 25"

Service Code
W4118 (HCPCS) Wheelchair seat depth, greater than 25"
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Wheelchair seat height, cost added option from manufacturer

Service Code
W4119 (HCPCS) Wheelchair seat height, cost added option from manufacturer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Disposable Bags for Inspirease Inhaler System, set of 3, each

Service Code
W4120 (HCPCS) Disposable Bags for Inspirease Inhaler System, set of 3, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Contoured or 3-piece head/neck supports with hardware, each

Service Code
W4130 (HCPCS) Contoured or 3-piece head/neck supports with hardware, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Basic head/neck support with hardware, each

Service Code
W4131 (HCPCS) Basic head/neck support with hardware, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Contoured or 3-piece head/neck support with multiadjustable hardware, each

Service Code
W4132 (HCPCS) Contoured or 3-piece head/neck support with multiadjustable hardware, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Basic head/neck support with multi-adjustable hardware, each

Service Code
W4133 (HCPCS) Basic head/neck support with multi-adjustable hardware, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Sub-asis bars with hardware, each

Service Code
W4139 (HCPCS) Sub-asis bars with hardware, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Abductor pads with hardware, pair

Service Code
W4140 (HCPCS) Abductor pads with hardware, pair
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity