92586
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation of a complete history and physical examination.
- Documented parent/child interview or patient interview containing DSM-5 diagnostic criteria and findings.
- Results of collateral assessments when available (for example, Vanderbilt or Conners questionnaires).
- Psychiatric evaluation report or clinical notes from psychiatrist, psychologist, or other behavioral health professional.
Key Coverage Criteria
- Automated auditory brainstem responses (ABR), evoked otoacoustic emissions (OAE), or OAE followed by ABR testing is consideredmedically necessaryto screen for hearing disorders foranyof the following indications:
- As initial screening for newborns and infants;or
- Infants (age less than 1 year) admitted to an ICU for 2 or more days;or
- Neonates during the 1st month of life when exposed to potential causes of hearing loss (for example, chemotherapy, hyperbilirubinemia that requires exchange transfusions, meningitis, or culture-positive sepsis);or
- To screen for hearing disorders in infants and children when behavioral audiometry is not reliable related to, but not limited to, inability to cooperate with other methods of hearing testing;or
- To screen for hearing disorders in children less than 36 months of age who passed the neonatal hearing screening test but are at risk of having sensorineural hearing loss;or
2 Active Policies
AMBETTER-CP.BH.124 — Attention Deficit Hyperactivity Disorder Assessment and Treatment
ANTHEM-CG-MED-49 — CG-MED-49 Auditory Brainstem Responses (ABRs) and Evoked Otoacoustic Emissions (OAEs) for Hearing Disorders
Related Codes
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