V5275 — Ear impression, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For sigmoid sinus resurfacing: diagnostic documentation that pulsatile tinnitus is resulting from "sigmoid sinus dehiscence or diverticulum" (imaging/clinical findings supporting that etiology).
- Documentation that "Medically correctable causes of tinnitus have been ruled out."
- Documentation that the member "has experienced severe tinnitus for more than 6 months."
- Documentation that the member "has tried and failed conservative tinnitus treatments, including counseling and reassurance, dietary modifications, and drug therapy."
Key Coverage Criteria
- Transcutaneous electrical nerve stimulation (TENS) as durable medical equipment (DME) for members with severe tinnitus when all of the following criteria are met: "Medically correctable causes of tinnitus have been ruled out;" "Member has experienced severe tinnitus for more than 6 months," and "Member has tried and failed conservative tinnitus treatments, including counseling and reassurance, dietary modifications, and drug therapy."
- Sigmoid sinus resurfacing for the treatment of pulsatile tinnitus resulting from sigmoid sinus dehiscence or diverticulum.
- HCPCS codes covered if selection criteria are met: A4595 (Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES)); E0720 (Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation); E0730 (Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation).
- ICD-10 codes covered if selection criteria are met: H81.01 - H81.09 (Meniere's disease); H93.11 - H93.19 (Tinnitus); H93.A1 - H93.A9 (Pulsatile tinnitus).
- No explicit "Covered Indications" section present in this document. The policy text does not state Medicare/Aetna coverage determinations. The document reviews clinical evidence for multiple interventions and the following clinical scenarios were evaluated in the literature:
- ICD-10 codes covered if selection criteria are met: H93.A1 - H93.A9 (Pulsatile tinnitus).
1 Active Policy
AETNA-CPB-0406 — Tinnitus Treatments
Related Codes
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