69905
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
10.98
Facility
$818.66
Non-Facility
$818.66
Documentation Required
- Preoperative and diagnostic test results where applicable: pure tone audiometry (PTA), word recognition scores, caloric testing, cervical/peri‑ocular VEMPs (cVEMP/oVEMP), and other vestibular function testing to document canal paresis or vestibular deficits.
- For SSCD: high‑resolution CT of the temporal bone demonstrating dehiscence and supportive VEMP results (lowered thresholds) and clinical documentation of sound/pressure‑induced vertigo or autophony.
- Documentation of use of AAO‑HNS diagnostic and treatment criteria in candidate selection (as used in cited studies).
- When intra‑tympanic aminoglycoside (gentamicin) is used, documentation that patient was counseled regarding risk of hearing loss and that gentamicin was selected for refractory unilateral disease where benefits outweigh risks.
Key Coverage Criteria
- For the treatment of superior semicircular canal dehiscence if diagnosis is confirmed by audiometry and computed tomography: Middle fossa craniotomy
- For the treatment of superior semicircular canal dehiscence if diagnosis is confirmed by audiometry and computed tomography: Trans-mastoid canal plugging
- Intra-tympanic / trans-tympanic dexamethasone injection for the treatment of sudden sensorineural hearing loss if members had failed conservative treatments including oral steroids or if members have a medical condition that prohibits the use of oral steroids
- CPT codes listed in the CPB are covered if selection criteria are met (see CPT list under 'CPT codes covered if selection criteria are met')
- ICD-10 diagnoses covered if selection criteria are met: H81.01 - H81.09 (Meniere's disease [active]); H83.8x1 - H83.8x9 (Other specified diseases of inner ear [superior semicircular canal dehiscence]); H90.3 - H90.A32 (Conductive and sensorineural hearing loss)
- Disabling vertigo due to Meniere's disease (MD) in a member who meets the Selection Criteria for Surgery (see below).
1 Active Policy
AETNA-CPB-0514 — Meniere's Disease and Related Disorders: Surgery
Related Codes
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