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, 2. Lop ears, 3. Cupped ears, or 4. Constricted ears. C. Medicaid does not cover otoplasty for children under the age of five (5). D. The medical record must include the relevant history and physical finding indicating the coverage criteria, and must include the following: 1. Photographs of frontal, lateral, and oblique ear positions. The name of the patient and the date of the photograph must be marked on each photograph. 2. Detailed medical history, 3. Hearing evaluation and test results, if performed, and 4. Physical examination.