CG-MED-96 Prefabricated External Infant Ear Molding Systems

This policy addresses prefabricated external infant ear molding systems for infants with congenital ear anomalies. Coverage is provided as medically necessary when treatment is initiated at 8 weeks of age or younger and is intended to improve a significant functional impairment (e.g., hearing), and as reconstructive when used to correct a significant variation from normal; it is considered cosmetic and not medically necessary when neither a significant functional impairment nor a significant variation from normal is present. Key limitation: the age-at-initiation requirement applies to medically necessary use.

"Prefabricated external infant ear molding systems are consideredmedically necessarywhen the following criteria are met:"

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