69320
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
16.75
Facility
$1426.55
Non-Facility
$1426.55
Documentation Required
- For reconstruction claimed to prevent inability to use eyewear: frontal, lateral, and posterior photographs with the individual's eyewear being worn that demonstrate the external ear deformity is preventing the functional ability to use eyewear for correction of a current visual deficit (explicitly required by policy).
- For indications involving hearing (reconstruction expected to improve hearing, reconstruction necessary to allow use of a conventional air conduction hearing aid, or ear molding for congenital malformation with functional hearing impairment): clinical documentation of congenital external ear malformation and documentation of functional hearing impairment (e.g., audiologic evaluation/audiogram, hearing loss assessment, and documentation that hearing is expected to improve or that ear anatomy prevents use of a conventional air-conduction hearing aid).
- For claims involving cochlear implant facilitation: documentation that external ear anatomy interferes with placement/usage of cochlear device microphone and that reconstruction is required to facilitate device use (clinical notes, device evaluation).
Key Coverage Criteria
- External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: hearing is expected to improve.
- External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: reconstruction is necessary to allow the use of a conventional air conduction hearing aid.
- External ear reconstruction for the treatment of an external ear deformity or the absence of an external ear is medically necessary when ANY of the following criteria is met: frontal, lateral, and posterior photographs with eyewear being worn demonstrate that the external ear deformity is preventing the functional ability to use eyewear for the correction of a current visual deficit.
- Non-surgical external ear molding is medically necessary for a congenital external ear malformation in an individual with a functional impairment of hearing.
- CPT 69310 (reconstruction of external auditory canal/meatoplasty) is considered medically necessary when the applicable policy criteria are met (e.g., for stenosis due to injury or infection).
- CPT 69320 (reconstruction external auditory canal for congenital atresia, single stage) is considered medically necessary when the applicable policy criteria are met.
1 Active Policy
CIGNA-0335 — Otoplasty and External Ear Reconstruction - (0335)
Related Codes
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