Does V5095 require prior authorization?

No, V5095 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for V5095?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`V5095`, Semi-implantable middle ear hearing prosthesis

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Confirmation that the device is FDA-cleared (when coverage is being considered for OTC or prescription hearing aids).
Coding/claims documentation: use of covered HCPCS/CPT/other codes only when selection criteria are met (policy lists HCPCS codes covered if selection criteria are met: S2230; V5030; V5050; V5070; V5095).

If coverage is being sought, confirmation of the member's plan benefits (because many Aetna plans exclude hearing aids) and any applicable plan limitations or exclusions.

When billing covered HCPCS codes, documentation showing that the selection criteria (medical necessity criteria above) are met.

Audiometric documentation demonstrating one of the medical necessity criteria: either (a) hearing thresholds 40 dB HL or greater at 500, 1000, 2000, 3000, or 4000 Hz; or (b) hearing thresholds 26 dB HL or greater at three of these frequencies; or (c) speech recognition less than 94 percent.

For implantable/semi-implantable devices: clinical documentation that the member has moderate-to-severe sensorineural hearing impairment and cannot tolerate an ear mold because of medical conditions (examples given: auricular atresia or severe chronic otitis externa).

Key Coverage Criteria

The Bose Hearing Aid and other FDA-cleared hearing aids available over the counter without a prescription as equally effective alternatives to hearing aids available only by prescription for persons whose hearing has been evaluated and meet medical necessity criteria for air conduction hearing aids, provided the member has a prescription for the hearing aid from a physician or provider licensed to prescribe hearing aids.
Air conduction hearing aids when the following criteria are met: Hearing thresholds 40 decibels (dB) HL or greater at 500, 1000, 2000, 3000, or 4000 hertz (Hz); or Hearing thresholds 26 dB HL or greater at three of these frequencies; or Speech recognition less than 94 percent.
Implantable hearing aids (e.g., the Esteem implantable hearing system and the Carina prosthesis) and semi-implantable hearing aids (e.g., the Maxum system and the Vibrant Soundbridge) for members who have moderate-to-severe sensorineural hearing impairment and can not tolerate an ear mold because of medical conditions (such as auricular atresia or severe chronic otitis externa).
HCPCS codes covered if selection criteria are met: S2230 (Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear), V5030 (Hearing aid, monaural, body worn, air conduction), V5050 (Hearing aid, monaural, in the ear), V5070 (Glasses, air conduction), V5095 (Semi-implantable middle ear hearing prosthesis).
ICD-10 codes covered if selection criteria are met: H90.3 - H90.8 (Sensorineural hearing loss and mixed conductive and sensorineural hearing loss), Q16.1 (Congenital absence, atresia and stricture of auditory canal (external)).
For benefit plans that do not exclude hearing aids: OTC and prescription hearing aids are eligible for coverage if they are cleared by the FDA and prescribed by a qualified healthcare provider and medical necessity criteria for hearing aids above are met.

2 Active Policies

ANTHEM-SURG.00084, Implantable Middle Ear Hearing Aids

AETNA-CPB-0612, Hearing Aids

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V5095, Semi-implantable middle ear hearing prosthesis