Does Z01.110 require prior authorization?

No, Z01.110 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z01.110`, Encounter for hearing examination following failed hearing screening

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Supporting audiologic tests and notes (audiograms, audiology reports) as applicable to demonstrate hearing status and support medical necessity.
For unilateral persistent otologic symptoms, MRI is required to exclude acoustic neuroma prior to or as part of the diagnostic evaluation (policy states: 'In all patients who have unilateral persistent otological symptoms, a MRI is required to exclude acoustic neuroma').
When ECoG is performed in conjunction with ABR for 'profound hearing loss', documentation should include audiometric results demonstrating pure tone average (PTA) of 90 dB HL or greater at 500, 1,000, 2,000 and 4,000 Hz (definition of 'profound hearing loss' provided in policy).

When ECoG is being used to evaluate suspected perilymphatic fistula, supporting documentation (as applicable) may include audiograms demonstrating sensorineural hearing loss, results of fistula testing (subjective fistula test, electronystagmography or platform testing), and endoscopic visualization findings; final diagnosis of fistula is made by direct inspection at surgery (policy describes these diagnostic steps — documentation of performed tests/results should be present if used clinically).

Key Coverage Criteria

H83.11 - H83.19: Labyrinthine fistula
H83.3X1 - H83.3X9: Noise effects on inner ear
H90.3: Sensorineural hearing loss, bilateral
H90.41 - H90.42: Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side
Electrocochleography (ECoG) is considered medically necessary for evaluation of members with symptoms of episodic dizziness (vertigo, imbalance) or tinnitus to rule out endolymphatic hydrops (Meniere's disease) and perilymphatic fistula.
ECoG is considered medically necessary when performed with auditory brainstem response (ABR) testing of members with profound hearing loss. (Profound hearing loss defined as pure tone average (PTA) of 90 dB HL or greater at 500 Hz, 1,000 Hz, 2,000 Hz and 4,000 Hz.)

3 Active Policies

ANTHEM-CG-MED-49, Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders

AMBETTER-CP.MP.134, Evoked Potential Testing

AETNA-CPB-0564, Electrocochleogram and Perilymphatic Pressure Measurement

`Z01.110`, Encounter for hearing examination following failed hearing screening

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

Z01.110, Encounter for hearing examination following failed hearing screening

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`Z01.110`, Encounter for hearing examination following failed hearing screening