REIMBURSEMENT POLICY

CMS-1500

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United Healthcare Services, Inc. 2018R7104A

Otoacoustic Emissions Testing Policy

Policy Number

2018R7104A Annual Approval Date

11/15/2017 Approved By Reimbursement Policy Oversight Committee

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT

*), Centers for Medicare and

Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plans reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider

contracts, the enrollees benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Payment Policies for Medicare & Retirement, UnitedHealthcare Community Plan Medicare and Employer & Individual please use this link. Medicare & Retirement and UnitedHealthcare Community Plan Medicare Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial.

Table of Contents

Overview Reimbursement Definitions Questions and Answers Attachments Resources Clinical Evidence Professional Societies and Guidelines

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REIMBURSEMENT POLICY

CMS-1500

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United Healthcare Services, Inc. 2018R7104A

History

Policy

Overview

UnitedHealthcare Community Plan has noticed an increase in utilization for OAE (otoacoustic emissions) testing in certain markets as a tool for routine screening. This has created increasing financial payments in these markets.

The American Academy of Pediatrics (AAP) Task Force on Newborn and Infant Hearing and the Joint Committee on Infant Hearing (JCIH) endorse the implementation of universal newborn hearing screening. Also, the U.S. Preventive Services Task Force (USPSTF) recommends screening for hearing loss in all newborn infants.

Otoacoustic emissions (OAEs) are low-intensity sounds emitted by functioning outer hair cells of the cochlea. OAEs are measured by presenting a series of very brief clicks to the ear through a probe that is inserted in the outer third of the ear canal. The probe contains a loudspeaker that generates the clicks and a microphone for measuring the resulting OAEs that are produced in the cochlea and are then reflected back through the middle ear into the outer ear canal. OAE testing requires no behavioral or interactive feedback by the individual being tested.

OAEs are used as a screening test for hearing in newborns. Other potential applications of OAE testing include screening children or at-risk populations for hearing loss, and characterizing sensitivity and functional hearing loss and differentiating sensory from neural components in people with known hearing loss.

The two most common types of OAE measurements are 1) transient evoked otoacoustic emissions (TEOAEs) which are sounds emitted in response to acoustic stimuli of very short duration; usually clicks but can be tone-bursts, and 2) distortion product otoacoustic emissions (DPOAEs) which are sounds emitted in response to two simultaneous tones of different frequencies. TOAEs are used to screen infants, validate other tests, and assess cochlear function, and DPOAEs are used to assess cochlear damage, ototoxicity, and noise-induced damage. Spontaneous otoacoustic emissions (SOAEs) are sounds emitted without an acoustic stimulus (i.e., spontaneously). Sustained-frequency otoacoustic emissions (SFOAEs) are sounds emitted in response to a continuous tone. At present, SOAEs and SFOAEs are not used clinically.

The OAE test is an effective screening measure for middle-ear abnormalities and for moderate or severe degrees of hearing loss, because normal OAE responses are not obtained if hearing thresholds are approximately 30- to 40-dB hearing levels or higher. The OAE test does not further quantify hearing loss or hearing threshold level. The OAE test also does not assess the integrity of the neural transmission of sound from the eighth nerve to the brainstem and, therefore, will miss auditory neuropathy and other neuronal abnormalities. Individuals with such abnormalities will have normal OAE test results but abnormal auditory brainstem response (ABR) test results (Harlor, 2009).

Reimbursement Guidelines

UnitedHealthcare Community Plan will deny CPT codes 92558, 92587 and 92588 when not submitted with a diagnosis on the attached diagnosis list for members age 4 years and over.

Neonatal hearing screening using otoacoustic emissions (OAEs) is medically necessary for infants who are 90 days or younger.

Otoacoustic emissions (OAEs) testing is medically necessary for the evaluation of hearing loss in the following:

infants and children age 3 years (up to, but not including, 4th birthday) or younger

children and adults who are or who are unable to cooperate with other methods of hearing testing (e.g. individuals with autism or stroke)

Auditory screening or diagnostic testing using otoacoustic emissions (OAEs) is not medically necessary for all other patient populations and conditions including ototoxic hearing changes in individuals treated with ototoxic medications.

There is inadequate evidence that hearing screening with OAEs is superior to screening audiometry in improving health outcomes such as timely facilitation of speech, language, and communication skills in older children or adults. There is also inadequate evidence to indicate that the use of diagnostic otoacoustic emissions (OAEs) testing is superior to screening audiometry in improving health outcomes such as timely facilitation of speech, language, and communication skills) in patients with other conditions such as ototoxic hearing changes in individuals treated with ototoxic medications,

REIMBURSEMENT POLICY

CMS-1500

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United Healthcare Services, Inc. 2018R7104A

noise-induced hearing loss, sudden hearing loss, tinnitus, and other suspected hearing loss.

State Exceptions

Kansas Kansas is exempt from this policy based on state requirements.

Definitions

OAE Otoacoustic emissions: low-intensity sounds emitted by functioning outer hair cells of the cochlea.

Questions and Answers

1

Q: Why doesnt UnitedHealthcare Community Plan reimburse for OET screening for members over the age of 4 years?

A: In order to comply with newborn hearing screening requirements and to follow guidelines from the research regarding testing of children, OET screening will be allowed for members up to age 4. There is inadequate evidence that hearing screening with OAEs is superior to screening audiometry in improving health outcomes such as timely facilitation of speech, language, and communication skills in older children or adults.

Codes

CPT code section

92558 Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transie