Despite the availability of billing codes for evaluation of audiologic rehabilitation status and audiologic rehabilitation (AR), not all private health plans cover these services.
The availability of audiologic rehabilitation billing codes is due, in part, to the 2006 efforts of the ASHA Health Care Economics Committee to add four codes to Current Procedural Terminology (CPT, ©American Medical Association, 2011): evaluation of audiologic rehabilitation status for the first hour of the evaluation (92626); each additional 15 minutes of evaluation (92627); audiologic rehabilitation, pre-lingual hearing loss (92630); and audiologic rehabilitation, post-lingual hearing loss (92633).
Two years later, also as a result of ASHA advocacy efforts, the diagnosis of speech-language delay due to hearing loss was added to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to differentiate this speech-language delay from delays related to other etiologies.
Coverage for audiologic rehabilitation varies not only among insurers, but also within insurers, depending on the beneficiary's specific plan. Audiologists and speech-language pathologists should ensure that the patient knows the specific terms of his or her coverage. The provider may advise the patient or patient's family to obtain a copy of the policy and any revisions made since the policy went into effect. For example, the CIGNA plan mentioned below has been effective since September 2010, with a scheduled review date of September 2011.
Companies use different names to refer to explanations of benefits: medical coverage policy (CIGNA), clinical policy bulletin (Aetna), and coverage determination guideline (United HealthCare). Some policies provide more detail than others, but all provide valuable information prior to initiation of treatment as well as for advocacy and appeals as needed. Policies may be more inclusive of all rehabilitative services; some, like Blue Cross Blue Shield (BCBS) of Illinois, even have a separate policy for cochlear implants.
Following are descriptions of audiologic rehabilitation coverage for major private health insurers.
Cigna's detailed policy (effective Sept. 15, 2010), considers audiologic rehabilitation a form of "speech therapy" and thus subject to the general policy about short-term rehabilitation in terms of the applicable benefit plan's schedule of copayments. CIGNA's policy is based on two guiding principles. First, according to CIGNA, although audiologic rehabilitation is widely used, its role has not been clearly delineated, except for those with cochlear implants. Second, audiologic rehabilitation needs to be structured, systematic, individualized, and goal-directed. Rehabilitative and habilitative therapies are included in the policy document.
CIGNA requires proof of medical necessity for audiologic rehabilitation, which is satisfied when all of the following seven criteria are met:
- The need is the result of trauma, tumor, or disease, or following cochlear or auditory brainstem device implant.
- A complete evaluation, including formal testing, has been completed by a certified SLP or audiologist.
- Treatment has the support of the treating physician.
- Treatment requires one-to-one intervention and supervision by SLPs or audiologists.
- The treatment plan includes specific tests and measures that will be used to document significant progress.
- Meaningful improvement is expected.
- Treatment includes transition from individual supervision to an individual- or caregiver-provided maintenance level on discharge.
Audiologists are included as providers of audiologic rehabilitation under the CIGNA policy. This provision is possible because of the removal of audiologic rehabilitation from the global speech-language treatment code (CPT 92507).
CIGNA does not cover audiologic rehabilitation for presbycusis. It also excludes other treatments deemed not medically necessary, including:
- Computer-based learning programs used for audiologic rehabilitation.
- School audiologic rehabilitation programs.
- Group treatment.
- Maintenance programs.
- Therapy or treatment provided to prevent or slow deterioration in function.
Some CIGNA plans limit treatment sessions to a specific number, even when medical necessity criteria are met. The plan also excludes behavioral training/treatment or services considered educational in nature.
Like CIGNA, Aetna considers audiologic rehabilitation medically necessary as a type of speech-language treatment. According to Aetna, the treatment program should start as soon as the patient is identified as having a hearing impairment, or following placement of a cochlear implant. Aetna expects the rehabilitation program following cochlear implant to be six to 10 sessions, each lasting approximately two and one-half hours. The policy is very brief (as compared to the CIGNA policy) and simply lists codes covered if selection criteria are met. Excluded codes or conditions are not listed.
United HealthCare includes audiologic rehabilitation as part of the policy for speech-language pathology services. The policy notes that the coverage is for the services of an SLP; it expands the statement to "(or) other licensed health care professional (within the scope of his/her licensure)," a description that would include—but does not specifically mention—an audiologist. Under the category of rehabilitation services or restorative therapy services, the policy states that audiologic rehabilitation includes speech-language treatment for covered health care services (e.g., an auditory device or cochlear implant).
United HealthCare provides additional clarification with two generic certificates of coverage (COCs), documents that specify the beneficiary's coverage. The COCs note that audiologic rehabilitation for post-cochlear implant is limited to 30 visits. United HealthCare does not limit audiologic rehabilitation therapy to post-cochlear implant. Treatment of injury affecting speech (e.g., otitis media as an illness, and potentially as an injury if it causes damage that results in hearing loss) is also addressed.
Blue Cross Blue Shield
BCBS does not have a national policy; coverage decisions are made by individual state or regional plans. For example, CareFirst (the BCBS plan for the District of Columbia, Maryland, and Virginia) has two medical policies. The first is for speech-language treatment that includes both habilitative and rehabilitative treatment as medically necessary. Like United HealthCare, BCBS also does not specifically name the audiologist as a provider of services, but includes the statement that "services must...be performed by a qualified provider in accordance with the practice standards outlined by the American Speech-Language-Hearing Association," a description that includes audiologists. Children with documented hearing loss that results in speech impairment are included in this policy. The second CareFirst policy is specifically for those with cochlear implants, for which audiologic rehabilitation is provided as a medical benefit separate from speech-language benefits.