H80.00 — Otosclerosis involving oval window, nonobliterative, unspecified ear
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The policy contains no explicit, dedicated 'Documentation Requirements' section.
- Coverage is conditional on 'selection criteria' being met (policy repeatedly states 'CPT codes covered if selection criteria are met' and 'ICD-10 codes covered if selection criteria are met'), therefore documentation must demonstrate that applicable selection criteria are met (selection criteria are not detailed in this document).
- Implied documentation to support coverage (inferred from policy content): documentation of hearing impairment diagnosis (relevant ICD-10 code), documentation of cochlear implant placement/status (e.g., Z96.21), clinical justification for aural rehabilitation (e.g., pre/post-implant audiologic evaluations, evaluation of auditory rehabilitation status [CPT 92626], and evidence the patient has not reached a plateau in performance if a cochlear implant user).
Key Coverage Criteria
- Aetna considers aural rehabilitation (including auditory verbal therapy [AVT]) medically necessary as speech therapy for members with hearing impairments and after placement of a cochlear implant.
- Auditory rehabilitation for members with cochlear implants (i.e., services after placement of a cochlear implant).
- Auditory rehabilitation services described by CPT codes when selection criteria are met: 92626 (Evaluation of auditory rehabilitation status; first hour), 92627 (each additional 15 minutes), 92630 (Auditory rehabilitation; pre-lingual hearing loss), 92633 (Auditory rehabilitation; post-lingual hearing loss).
- Related services/care in conjunction with cochlear device implantation (CPT 69930) and cochlear device/system/supplies (HCPCS L8614-L8624) when selection criteria are met.
- Covered ICD-10 diagnoses (when selection criteria are met): H74.01-H74.93 (Other disorders of middle ear/mastoid), H80.00-H80.93 (Otosclerosis), H81.01-H81.09 (Meniere's disease), H90.0-H90.8 (Conductive and sensorineural hearing loss), H93.011-H93.099 and H93.211-H93.93 (Other disorders of ear, not elsewhere classified), and Z96.21 (Cochlear implant status).
- Auditory verbal therapy (AVT) is included where indicated above (policy explicitly references AVT as included in 'aural rehabilitation').
2 Active Policies
AETNA-CPB-0034 — Aural Rehabilitation
AETNA-CPB-0524 — Zoledronic Acid
Related Codes
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