Coverage Policy Manual
Policy #: 2011036
Category: PPACA Preventive
Initiated: September 2010
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: HEARING LOSS SCREENING IN NEWBORNS UP TO AGE 21

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
Effective August 2017
 
Screening for hearing loss in children is covered for members of “non-grandfathered plans” without cost sharing, (i.e., deductible, co-pay, or co-insurance) as follows:
 
    • All newborn infants (If not done at birth (e.g., newborn delivered at home or discharged from Neonatal Intensive Care Unit), screening should be completed within the first month of life; And
    • At the 4th through the 36th month visits,  the 7 year and 9 year visits, if there are positive responses to risk screening question, diagnostic audiologic assessment should be performed; AND
    • At the 4th, 5th, 6th, 8th and 10th year, audiometry is recommended.  
    • Audiometry screening with 6,000 and 8,000 Hz high frequencies is recommended once between 11 through 14 years of age, once between 15 through 17 years of age and  once between 18 through 21 years of age.
 
The appropriate ICD-9 code to report these services is V72.19 or V20.31 or V20.32, V20.2 or V70.0.
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129, Z00.110, Z00.111, Z00.00-Z00.01 or Z01.10.
 
Codes that may be used to report these services include 92551, 92552, 92558, 92567, 92579, 92582 or 92586.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Effective August 2013- July 2017
Screening for hearing loss in children is covered for members of “non-grandfathered plans” without cost sharing, (i.e., deductible, co-pay, or co-insurance) as follows:
 
    • All newborn infants (If not done at birth (e.g., newborn delivered at home or discharged from Neonatal Intensive Care Unit), screening should be completed within the first month of life; And
    • At the 4th through the 48th month and from 7 years to 21 years, if there are positive responses to risk screening question, diagnostic audiologic assessment should be performed; AND
    • At the 5th, 6th and 10th year, audiometry is recommended.
 
The appropriate ICD-9 code to report these services is V72.19 or V20.31 or V20.32, V20.2 or V70.0.
 
The appropriate ICD-10 codes to report these services are Z00.121, Z00.129, Z00.110, Z00.111, Z00.00-Z00.01 or Z01.10.
 
Codes that may be used to report these services include  92551, 92552, 92558, 92567 (added 8/2015) 92579, 92582 or 92586.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
Effective prior to August 2013
Screening for hearing loss in newborns, 28 days of age or less, is covered for members of “non-grandfathered plans” without cost sharing, (i.e., deductible, co-pay, or co-insurance).  The patient population considered here includes all newborn infants.
 
Screening for hearing loss in newborns is mandated by law in some states.  It is typically performed as part of the newborn care in a hospital.   
 
The appropriate ICD-9 code to report these services is V72.19 or V20.31 or V20.32, V20.2 or V70.0.
 
Codes that may be used to report these services include  92551, 92552, 92558, 92579, 92582 or 92586.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 

Rationale:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for hearing loss in all newborn infants. (B recommendation)
 
Children with hearing loss have increased difficulties with verbal and nonverbal communication skills, increased behavioral problems, decreased psychosocial well-being, and lower educational attainment compared with children with normal hearing.
 
Because half of the children with hearing loss have no identifiable risk factors, universal screening (instead of targeted screening) has been proposed to detect children with permanent congenital hearing loss (PCHL). There is good evidence that newborn hearing screening testing is highly accurate and leads to earlier identification and treatment of infants with hearing loss.
 
Risk factors associated with a higher incidence of permanent bilateral congenital hearing loss include NICU admission for ≥2 days, several congenital syndromes, family history of hereditary childhood sensorineural hearing loss, craniofacial abnormalities, and certain congenital infections. However, ~50% of infants with permanent bilateral congenital hearing loss do not have any known risk factors.
 
Screening programs should be conducted by using a 1- or 2-step validated protocol. A frequently used protocol requires a 2-step screening process, which includes otoacoustic emissions (OAEs) followed by auditory brainstem response (ABR) in those who failed the first test. Equipment should be well maintained, staff should be thoroughly trained, and quality-control programs should be in place to reduce avoidable false-positive test results. Programs should develop protocols to ensure that infants with positive screening-test results receive appropriate audiologic evaluation and follow-up after discharge. Newborns delivered at home, birthing centers, or hospitals without hearing screening facilities should have some mechanism for referral for newborn hearing screening, including tracking of follow-up.
 
All infants should have hearing screening before 1 month of age. Those infants who do not pass the newborn screening should undergo audiologic and medical evaluation before 3 months of age for confirmatory testing. Because of the elevated risk of hearing loss in infants with risk indicators, an expert panel has made a 2000 recommendation that these children should undergo periodic monitoring for 3 years.
 

CPT/HCPCS:
92551Screening test, pure tone, air only
92552Pure tone audiometry (threshold); air only
92567Tympanometry (impedance testing)
92579Visual reinforcement audiometry (VRA)
92582Conditioning play audiometry
92586Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Screening for Hearing loss in Newborns, July 2008: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf08/newbornhear/newbhearrs.htm


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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