Z01.10 — Encounter for examination of ears and hearing without abnormal findings
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supporting audiologic tests and notes (audiograms, audiology reports) as applicable to demonstrate hearing status and support medical necessity.
- For unilateral persistent otologic symptoms, MRI is required to exclude acoustic neuroma prior to or as part of the diagnostic evaluation (policy states: 'In all patients who have unilateral persistent otological symptoms, a MRI is required to exclude acoustic neuroma').
- When ECoG is performed in conjunction with ABR for 'profound hearing loss', documentation should include audiometric results demonstrating pure tone average (PTA) of 90 dB HL or greater at 500, 1,000, 2,000 and 4,000 Hz (definition of 'profound hearing loss' provided in policy).
- Clinical documentation of symptoms and rationale for testing: record of episodic dizziness (vertigo, imbalance) and/or tinnitus and the clinical intent to rule out endolymphatic hydrops (Meniere's disease) or perilymphatic fistula.
Key Coverage Criteria
- H83.11 - H83.19: Labyrinthine fistula
- H83.3X1 - H83.3X9: Noise effects on inner ear
- H90.3: Sensorineural hearing loss, bilateral
- H90.41 - H90.42: Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side
- Electrocochleography (ECoG) is considered medically necessary for evaluation of members with symptoms of episodic dizziness (vertigo, imbalance) or tinnitus to rule out endolymphatic hydrops (Meniere's disease) and perilymphatic fistula.
- ECoG is considered medically necessary when performed with auditory brainstem response (ABR) testing of members with profound hearing loss. (Profound hearing loss defined as pure tone average (PTA) of 90 dB HL or greater at 500 Hz, 1,000 Hz, 2,000 Hz and 4,000 Hz.)
1 Active Policy
AETNA-CPB-0564 — Electrocochleogram and Perilymphatic Pressure Measurement
Related Codes
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