BlueCross and BlueShield of Montana Medical Policy/Codes
Evaluation of Hearing Impairment
Chapter: Medicine: Tests
Current Effective Date: December 27, 2013
Original Effective Date: November 01, 1996
Publish Date: September 27, 2013
Revised Dates: March 1, 2005; November 1, 2007; March 1, 2010; July 29, 2013
Description

Hearing impairment or hearing loss is a reduction in the ability to perceive sound. The loss may range from slight to complete deafness.

Audiometric studies are diagnostic tests that evaluate sensorineural and conductive hearing losses. Conductive hearing loss is the result of disorders of the external or middle ear; sensory hearing loss is secondary to disturbance of the cochlea; neural hearing loss results from disease of the auditory (eighth) nerve or central auditory channel connections. Sensory and neural hearing losses are frequently included under the term sensorineural hearing loss. Mixed or combined hearing loss involves disturbances of both conductive and sensorineural mechanisms. A variety of tests have been designed to evaluate central auditory processing, which is a higher order cortical function that processes auditory information. Therefore, central auditory processing tests do not strictly evaluate hearing impairment, and thus are not formally considered in this policy. (See Rationale section for further general discussion of central auditory processing.)

The various audiometric tests can be subdivided into standard batteries that are typically used as part of the initial work-up of patients presenting with hearing impairment, as well as specialized tests that are typically used in specific clinical situations. The standard batteries vary according to whether the patient is an adult, child, or infant. The tests are briefly defined as follows.

Standard Battery of Tests for Adults and Children

1. Pure-tone audiometry, air and bone conduction

This test is a standard audiometric study that uses tones of various frequencies and intensities as auditory stimuli to measure hearing. As air conduction is the usual method of sound transmission, air audiometry uses the external and middle ear in the transmission of sound to the cochlea and beyond. Bone-conduction audiometry involves the vibration of the skull by direct contact with an oscillating device that is thought to set the cochlear fluids into motion, bypassing the external and middle ear. When bone-conduction thresholds are better than air-conduction thresholds, the hearing loss is conductive. When bone-conduction thresholds are the same as air-conduction thresholds, the hearing loss is sensorineural. When bone-conduction thresholds are reduced but are still better than air conductions, the loss is mixed or combined.

2. Speech audiometry

This test is a standard audiometric study that measures overall performance in hearing, understanding, and responding to speech for a general assessment of hearing and an estimate of degree of practical handicap. It may include a speech recognition test, in which the patient repeats words back, and a speech reception threshold, which determines when the patient can first hear speech. It may also be used to reaffirm the findings of the pure-tone audiometry and to diagnose pseudohypacusis (a non-existent or false hearing loss).

3. Word recognition tests

This category includes filtered speech tests and synthetic sentence identification. These tests specifically assess the patient’s ability to discriminate spoken words.

4. Acoustic reflex test and acoustic reflex decay

These tests measure the changes in the ear’s ability to conduct sound to the cochlea. Reflexes, called acoustic reflexes, exist and involve middle ear function. Absence of the acoustic reflex may be indicative, among other things, of lesions of the middle ear, acoustic tumor, otosclerosis, facial nerve involvement of the probe ear side, and surgical removal or congenital absence of the stapes. These tests may be used in assessing the hearing of neonates and other children too young to cooperate in the audiometric testing of functional hearing loss.

5. Tympanometry (impedance testing)

This is a standard series of tests to measure the ability of the middle ear to conduct sound. It is particularly useful in the identification of fluid in the middle ear and in the anatomic localization of facial nerve paralysis.

Additional Standard Battery of Tests for Children Only

1. Select picture audiometry

This test is used to evaluate hearing-impaired children. It involves the use of pictures on cards and the child’s ability to correctly identify objects based on audiologic direction.

2. Conditioning play audiometry

This is usually performed to test hearing impairment in children 2 to 4 years of age. The child is taught to put an object in a specific place, e.g., a marble in a box or a cow in the barnyard when a specific sound is heard.

Standard Battery of Tests for Infants Only

1. Auditory evoked potential (also called auditory brainstem response [ABR])

This is an electrophysiologic measure of auditory function that uses responses produced by the auditory nerve and the brainstem and helps differentiate sensory from neural hearing loss. The response is the waveform averaged over many auditory clicks. It may be helpful in the diagnosis of cerebellopontine angle tumors and acoustic neuromas, is used as a monitor in posterior fossa surgery, and may help to establish a hearing threshold for infants and difficult-to-test patients.

2. Visual reinforcement audiometry (VRA)

The VRA is part of a battery of tests used in the determination of infant hearing loss. The premise of the test is that the rate of patient response is increased by the use of reinforcement.

3. Evoked otoacoustic emissions (OAE)

Otoacoustic emissions are sounds measured in the external ear canal that are a reflection of the working of the cochlea. Probe and click stimuli are used in the performance of this test. OAE is used in the screening as well as the diagnosis of hearing impairment in neonates and young children.

4. Acoustic reflex test

See Standard Battery of Tests for Adults and Children Only, No. 4

Specialized Tests for Adults and Children

1. Auditory Evoked Potential

See Standard Battery of Tests for Infants Only, No. 1

2. Electrocochleography (ECochG)

This is a measure of the electrical potentials generated in the inner ear as a result of sound stimulation. This test may be used in the evaluation of endolymphatic hydrops or Meniere’s disease.

3. Tone decay test

This test involves the presentation of a continuous tone to determine whether the threshold for the tone has changed (becomes poorer) over time. The test helps differentiate sensory from neural hearing loss, and is used in the diagnosis of cochlear versus retrocochlear lesions and eighth nerve tumors. While this test is still in use, the auditory evoked potential test is largely used in place of the tone decay test.

4. Stenger test, pure tone or speech

This test uses a tone presented simultaneously to both ears and is based on the principle that the tone is perceived only in the ear that receives the greater intensity. It is useful in the diagnosis of pseudohypacusis (hypacusis is a hearing impairment of a conductive or a neurosensory nature, and pseudohypacusis is a non-existent [false] hearing loss.

5. Sensorineural acuity level (SAL) test

This test measures the extent of sensorineural hearing loss and is used in the detection of pseudohypacusis among children. It is not a commonly performed test. There are several different tests in use, including one in which a bone-conduction vibrator is placed at the center of the forehead and the threshold shift for a normal ear versus an ear with sensorineural hearing loss is analyzed.

6. Evoked otoacoustic emissions

While this test is considered part of the standard battery of tests in infants, it is considered a specialized test in adults and children. For a description, see Standard Battery of Tests for Infants Only, No. 3.

Automated Audiology

Automated audiology is different from manual audiometric testing (testing conducted by a clinician [audiologist or physician]). Audiologist may use many computer-assisted devices for procedures such as otoacoustic emissions and evoked potentials requiring the constant presence and vigilance of the audiologist to ensure data gathering for test interpretation. In contrast, automated devices refer to equipment that follows a specified algorithm to determine what action to take next and does not include ongoing monitoring and vigilance by the clinician.

One type of automated audiometry device is the Otogram™ which was approved by the FDA in 2007. The Otogram is a computer-controlled, audiometric instrument combining the functions of an Audiometer, Distortion Product Otoacoustic Emissions Analyzer and Auditory Acoustic Impedance/Admittance Tester (i.e. Tympanometer) The FDA notes that the Otogram is indicated for use by trained healthcare professionals on both adult and pediatric subjects for measurement of audiometric parameters to identify and supply data to help diagnose hearing loss and ear disorders.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

STANDARD BATTERY OF TESTING

Tests identified as standard battery are considered medically necessary as part of the initial work-up of a patient with hearing impairment in the corresponding age group.

ADULT

CHILD

INFANT

Pure-Tone Audiometry:

  • air conduction
  • bone conduction
  • masking (if air-bone gap is present)

Speech Audiometry:

  • speech recognition thresholds (SRT)
  • word recognition (WR) ability

Basic Immittance Test Battery:

  • tympanometry
  • acoustic reflex measurement

Same as adults (age dependent):

  • Pure Tone Audiometry,
  • Speech Audiometry,
  • Basic Immittance

Select Picture Audiometry

Conditioning Play

Audiometry

Auditory Evoked or Auditory Brainstem

Response (ABR)

Visual Reinforcement

Audiometry (VRA)

Evoked Otoacoustic Emissions (OAE)

Acoustic Reflex Measurement

SPECIALIZED TESTS

Tests identified as specialized would not be part of the initial work up of patients presenting with hearing impairment, but may be considered medically necessary when initial diagnostic tests are inconclusive.

 

ADULT

CHILD

Auditory Evoked Potentials or Auditory Brainstem Response (ABR) for:

  • difficult-to-test patients,
  • neurotologic assessment,
  • retrocochlear pathology (e.g., acoustic neuromas or other lesions)

Electrocochleography (EcochG) for diagnosis of endolymphatic hydrops

Tone Decay Test (tone decay has been largely replaced by ABR but is still in use) for diagnosis of cochlear vs. retrocochlear

Stenger Test, pure tone or speech for diagnosis of pseudohypacusis

Same as adults for:

  • ABR
  • EcochG
  • Tone Decay
  • Stenger Test

Evoked Otoacoustic Emissions (OAE)

Sensorineural Acuity Level (SAL) for diagnosis of pseudohypacusis

Audiometric studies are considered medically necessary in illnesses or injuries including, but not limited to, the following:

  • Hearing loss;
  • Otitis media;
  • Ménière's disease;
  • Labyrinthitis;
  • Vertigo;
  • Tinnitus;
  • Cochlear otosclerosis;
  • Neoplasms of the auditory or central nervous system;
  • Congenital anomalies;
  • Surgery involving the auditory and/or central nervous system, e.g., skull-based tumors such as acoustic neuroma and meningioma;
  • Facial nerve paralysis (Bell's palsy);
  • Bacterial meningitis;
  • Exposure to intense noise;
  • Ototoxic drugs; OR
  • Fractures of the temporal bone or trauma affecting the central auditory pathways.

The following audiometric tests are considered obsolete and thus are considered not medically necessary:

  • Lombard test (replaced by the Stenger test and auditory evoked potential);
  • Alternate binaural loudness balance test;
  • Short increment sensitivity test (replaced by pure tone audiometry and auditory evoked potential); and
  • Bekesy audiometry.

The following audiometric tests are considered experimental, investigational and/or unproven:

  • Staggered spondaic word test;
  • Synthetic sentence identification test.

Automated audiometry is considered experimental, investigational and/or unproven for all indications.

NOTE:  This policy no longer addresses tests of central auditory processing, since these tests do not evaluate hearing impairment.

Rationale

The tests of hearing impairment listed in the policy here are considered standard tests of hearing impairment and thus the specific diagnostic parameters of each of these tests will not be considered further. In 2000, the American Academy of Pediatrics, as a participant in the Joint Committee on Infant Hearing, published a position statement regarding early hearing detection. (1) This statement recommended that all infants have access to hearing screening using a physiologic measure, with the goal that all infants who do not pass the birth admission screen and any subsequent rescreening begin appropriate audiologic and medical evaluations to confirm the presence of hearing loss before 3 months of age. The position statement noted that otoacoustic emission (OAEs) or auditory brainstem response (ABR) are physiologic techniques that have been successfully used for newborn screening. For example, hospitals may screen with otoacoustic emissions technology or auditory brainstem response technology and retest infants who "refer" with the same or other technology.

Central Auditory Processing

When this policy was first issued in 1997, tests of central auditory processing (CAP) were considered investigational. These tests are no longer formally considered in the policy statement, since tests of central auditory processing are not tests of hearing impairment, per se, but tests of how auditory information is processed by the brain. For example, central auditory processes are responsible for sound localization and lateralization, auditory discrimination, auditory pattern recognition, and temporal aspects of audition. Tests of CAP are commonly recommended for children with dyslexia, attention deficit disorder, or other learning or behavioral disabilities. (2) The results of the test may be used to tailor specific teaching or behavioral strategies, and thus depending on the contract or benefit design may be considered part of the mental health benefits, or contractually excluded as an evaluation of a learning disability.

An overview of the literature reveals numerous articles describing various tests of central auditory processing. It would appear that the concept of such testing is widely accepted among the medical and audiology community. This acceptance challenges the determination that tests of CAP would still be considered investigational; however, an evidence-based approach to their evaluation is limited due to the multiple different batteries of tests that have been explored (3, 4), the lack of a gold standard test for comparison, the heterogeneous nature of patients that have been tested (based both on age and symptoms), and the uncertain impact on the overall health of the patient. In 1996, the American Speech Language Hearing Association published a task force report on CAP and noted that there was persistent controversy over CAP and its disorders and how it should be defined, identified, and ameliorated through intervention. (5) These same concerns were echoed in a subsequent 2002 consensus report. (6)

2005 Update

A literature search based on the MEDLINE database for the period of 2004 through June 2005 did not identify additional articles that would prompt reconsideration of the policy statement, which remains unchanged. No further review is scheduled.

2013 Update

A search of peer reviewed literature through October 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy concerning evaluation of hearing impairment other than what is identified below specific to Automated Audiometry.

Automated Audiometry

Yu et al., 2011, reported on a small study assessing the validity of the Otogram on patients with bilateral mixed, bilateral conductive and unilateral conductive hearing loss, which are deemed “difficult-to-test”. In this study, 28 difficult to test individuals were given three audiograms; two were performed by an audiologist and the third by the Otogram. The audiograms conducted by the audiologist were compared to establish test-retest reliability. The Otogram was then compared with the testing performed by the audiologists. The authors reported that the audiograms performed by the audiologists had high levels of agreement with over 90 percent of air and bone conduction thresholds within 10dB of each other. In the Otogram versus audiologist comparison, only air conduction conditions had high levels of agreement with the percentage of thresholds within 10 dB. Bone conduction conditions did not yield the same high levels of agreement as did the air conduction conditions. The authors concluded that additional research is needed to determine the reason for these differences and ways to control for them. (7)

A systematic review and metaanalysis conducted in 2013 noted: (10) “Automated audiometry provides an accurate measure of hearing threshold, but validation data are still limited for (a) automated bone conduction audiometry; (b) automated audiometry in children and difficult-to-test populations; and (c) different types and degrees of hearing loss”.

The American Speech-Language Hearing Association (ASHA) recommends that hearing screening be conducted under the supervision of an audiologist holding the ASHA Certificate of Clinical Competence (CCC). (9) 

Studies are limited comparing automated audiometry to manual audiometry performed by an audiologist. The effectiveness of automated auxometry has not been effectively proven equivalent to audiometry performed by an audiologist.

No literature found that would change the coverage position of this medical policy specific to any other indication addressed on this document.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

20.31, 95.41, 95.42, 95.43, 95.46, 95.47, 191.6, 192.3, 198.3, 198.4, 225.0, 225.1, 225.4, 237.5, 237.6, 239.6, 239.7, 320.81, 320.82, 320.9, 351.0, 382.9, 386.00-386.04, 386.30-386.35, 387.2, 388.30-388.32, 388.5, 389.00-389.08, 389.10-389.18, 744.04, 767.5, 780.4, 801.00-801.99, 951.5

Procedural Codes: 0208T, 0209T, 0210T, 0211T, 0212T, 92550, 92551, 92552, 92553, 92555, 92556, 92557, 92558, 92560, 92561, 92562, 92564, 92563, 92565, 92567, 92568, 92570, 92571, 92572, 92575, 92576, 92577, 92579, 92582, 92583, 92584, 92585, 92586, 92587, 92588
References
  1. American Academy of Pediatrics. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000; 106(4):798-817.
  2. Bamiou DE, Musiek FE, Luxon LM. Aetiology and clinical presentations of auditory processing disorders – a review. Arch Dis Child 2001; 85(5):361-5.
  3. Amos NE, Humes LE. SCAN test-retest reliability for first and third grade children. J Speech Lang Hear Res 1998; 41(4):834-45.
  4. Domitz DM, Schow RL. A new CAPD battery – multiple processing assessment: factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2):101-11.
  5. Task Force on Central Auditory Processing Consensus Development. American Speech-Language-Hearing Association. Central auditory processing: status of research and implications for clinical practice. Am J Audiol 1996; 5:41-54.
  6. Jerger J, Musiek F. Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000; 11(9):467-74.
  7. Yu, J. et al., “Automated Hearing Tests: Applying the Otogram to Patients who are Difficult to Test,” Journal of Otolaryngology-Head & Neck Surgery, Volume 40, issue 5, 2011, pp. 376-383.
  8. FDA. 510(k) Supplementary Information K070118. Accessed 10//2013 at www.fda.gov .
  9. American Speech-Language-Hearing Association, “Hearing Screening and Testing,”  http://www.asha.org .   (October 15, 2012).
  10. Mahomed F, Swanepoel D.W. et al. Validity of Automated Threshold Audiometry: A Systematic Review and Meta-Analysis. Ear Hear. 2013 May 31.
History
July 2013  Policy formatting and language revised.  Title changed from "Hearing and Balance Impairment, Evaluation of" to "Evaluation of Hearing Impairment".
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Evaluation of Hearing Impairment