405 IAC 5-22-7 Audiology services

Sec. 7. (a) Audiology services are subject to the following restrictions: (1) The physician must certify in writing the need for audiological assessment or evaluation. (2) The audiology service must be rendered by a licensed audiologist or a person registered for his or her clinical fellowship year who is supervised by a licensed audiologist. A registered audiology aide can provide services under the direct on-site supervision of a licensed audiologist under 880 IAC 1-1. (3) When a member is to be fitted with a hearing amplification device, by either the audiologist or a registered hearing aid specialist, a medical clearance and audiometric test form must be completed in accordance with instructions given below and submitted with the request for prior authorization. This form must be complete and must include the proper signatures, where indicated, before the prior authorization request will be reviewed by the department. (4) Initial audiological assessments are limited to one (1) assessment every three (3) years per member. If more frequent audiological assessments are necessary, prior authorization is required. (b) Provision of audiology services are subject to the following criteria: (1) All requests for prior authorization will be reviewed on a case-by-case basis by the contractor. (2) Member history must be completed by any involved professional. (3) The referring physician must complete Part 2 of the Medical Clearance and Audiometric Test Form no earlier than six (6) months prior to the provision of the hearing aid. Children fourteen (14) years of age and under must be examined by an otolaryngologist; older members may be examined by a licensed physician if an otolaryngologist is not available. (4) All testing must be conducted in a sound-free enclosure. If a member is institutionalized and his or her physical or medical condition precludes testing in a sound-free enclosure, the ordering physician must verify medical confinement in the initial order for audiological testing. The audiological assessment must be conducted by a licensed audiologist, clinical fellowship year audiologist, or otolaryngologist. Testing conducted by other professionals and cosigned by an audiologist or otolaryngologist will not be reimbursed by Medicaid. If the audiological evaluation reveals one (1) or more of the following conditions, the member must be referred to an otolaryngologist for further evaluation: (A) Speech discrimination testing indicates a score of less than sixty percent (60%) in either ear. (B) Pure tone testing indicates an air bone gap of fifteen (15) decibels or more for two (2) adjacent frequencies in the same ear. (5) The hearing aid evaluation may be completed by the audiologist or registered hearing aid specialist. The results must be documented on the prior authorization request and indicate that significant benefit can be derived from amplification before prior authorization may be granted. (6) The hearing aid contract portion of the audiometric test form must be signed by a registered hearing aid specialist. (7) Audiological assessments rendered more frequently than every three (3) years will be assessed on a case-by-case basis, based upon documented otological disease. (c) Audiologic procedures cannot be fragmented and billed separately. Hearing tests, such as whispered voice and tuning fork, are considered part of the general otorhinolaryngologic services and cannot be reported separately as follows: (1) Basic comprehensive audiometry include pure tone, air and bone threshold and discrimination. The above descriptions refer to testing of both ears. (2) All other audiometric testing procedures will be reimbursed on an individual basis, only for such medically necessary test procedures. (d) The following audiological services do not require prior authorization: (1) A screening test indicating the need for additional medical examination. Screenings are not reimbursed separately by Medicaid. (2) The initial assessment of hearing. (3) Determination of suitability of amplification and the recommendation regarding a hearing aid. (4) The determination of functional benefit to be gained by the use of a hearing aid. (5) Audiology services provided by a nursing facility or large private or small ICF/IID, which are included in the facility's established per diem rate.