4.  Stenger test, pure tone or speech 
This test uses a tone presented simultaneously to both ears and is based on the principle that the tone is perceived only in the ear that receives the greater intensity. It is useful in the diagnosis of pseudohypacusis (Hypacusis is a hearing impairment of a conductive or a neurosensory nature, and pseudohypacusis is a non-existent [false] hearing loss.)

5.  Sensorineural acuity level (SAL) test
This test measures the extent of sensorineural hearing loss and is also used in the detection of pseudohypacusis among children. It is not a commonly performed test. There are several different tests in use, including one in which a bone-conduction vibrator is placed at the center of the forehead and the threshold shift for a normal ear versus an ear with sensorineural hearing loss is analyzed.

6.  Evoked otoacoustic emissions
While this test is considered part of the standard battery of tests in infants, it is considered a specialized test in adults and children. For a description, see Standard Battery of Tests for Infants Only, No. 3.

Obsolete Audiometric Tests:

The following audiometric tests are considered obsolete and thus are considered NOT MEDICALLY NECESSARY:

• Lombard test (replaced by the Stenger test and auditory evoked potential)
• Alternate binaural loudness balance test
• Short increment sensitivity test (replaced by pure tone audiometry, auditory evoked potential)
• Bekesy audiometry

Investigational Audiometric Tests:*
 
The following audiometric tests are considered INVESTIGATIONAL:

• Staggered spondaic word test
• Synthetic sentence identification test

Policy  Guidelines:
Audiometric studies may be medically necessary in illnesses or injuries including, but not limited to, the following:

• Hearing loss
• Otitis media
• Méniére’s disease
• Labyrinthitis
• Vertigo (dizziness)
• Tinnitus
• Cochlear otosclerosis
• Neoplasms of the auditory or central nervous system
• Congenital anomalies
• Surgery involving the auditory and/or central nervous system, e.g., skull-based tumors such as acoustic neuroma and meningioma
• Facial nerve paralysis (Bell’s palsy)
• Bacterial meningitis
• Exposure to intense noise
• Ototoxic drugs
• Fractures of the temporal bone or trauma affecting the central auditory pathways

Audiometric studies using calibrated electronic equipment are technical service codes and only payable in a place of service office, skilled nursing home, nursing facilities, state or local health clinic, community hearing and speech centers and independent clinics. The ONLY exception for payment in an inpatient hospital or outpatient hospital setting are those audiometric studies that CMS recognizes separate payment of a professional component (modifier 26).  

Benefit Application
BlueCard/National Account Issues
Contract or benefit restrictions or exclusions for preventive services may apply to audiometric screening tests. However, many states have mandated universal newborn screening for hearing impairment.

For adult patients, many contracts do not provide benefits for hearing aids, the prescription or fitting of hearing aids or for testing for this purpose. Some Plans do not provide benefits for services related to hearing impairment/loss in the standard contracts but offer riders to cover these services.

Benefits are typically provided for medically necessary hearing tests and the prescription of hearing aids by audiologists or physicians, but these benefits may not apply to sellers of hearing aids who are not qualified providers.

Rationale
The tests of hearing impairment listed in the policy here are considered standard tests of hearing impairment and, thus, the specific diagnostic parameters of each of these tests will not be considered further. In 2000, the American Academy of Pediatrics, as a participant in the Joint Committee on Infant Hearing, published a position statement regarding early hearing detection.¹ This statement recommended that all infants have access to hearing screening using a physiologic measure, with the goal that all infants who do not pass the birth admission screen and any subsequent rescreening begin appropriate audiologic and medical evaluations to confirm the presence of hearing loss before 3 months of age. The position statement noted that otoacoustic emission (OAEs) or auditory brainstem response (ABR) are physiologic techniques that have been successfully used for newborn screening. For example, hospitals may screen with otoacoustic emissions technology or auditory brainstem response technology and retest infants who "refer" with the same or other technology.

Central Auditory Processing
When this policy was first issued in 1997, tests of central auditory processing (CAP) were considered investigational. These tests are no longer formally considered in the policy statement, since tests of central auditory processing are not tests of hearing impairment, per se, but tests of how auditory information is processed by the brain. For example, central auditory processes are responsible for sound localization and lateralization, auditory discrimination, auditory pattern recognition and temporal aspects of audition. Tests of CAP are commonly recommended for children with dyslexia, attention deficit disorder or other learning or behavioral disabilities.² The results of the test may be used to tailor specific teaching or behavioral strategies, and, thus, depending on the contract or benefit design may be considered part of the mental health benefits, or contractually excluded as an evaluation of a learning disability.

An overview of the literature reveals numerous articles describing various tests of central auditory processing. It would appear that the concept of such testing is widely accepted among the medical and audiology community. This acceptance challenges the determination that tests of CAP would still be considered investigational; however, an evidence-based approach to their evaluation is limited due to the multiple different batteries of tests that have been explored,^3,4 the lack of a gold standard test for comparison, the heterogeneous nature of patients that have been tested (based both on age and symptoms) and the uncertain impact on the overall health of the patient. In 1996, the American Speech Language Hearing Association published a task force report on CAP and noted that there was persistent controversy over CAP and its disorders and how it should be defined, identified and ameliorated through intervention.⁵ These same concerns were echoed in a subsequent 2002 consensus report.⁶

2005 Update
A literature search based on the MEDLINE database for the period of 2004 through June 2005 did not identify additional articles that would prompt reconsideration of the policy statement, which remains unchanged. No further review is scheduled.

References:

1. American Academy of Pediatrics. Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics 2000; 106(4):798-817.
2. Bamiou DE, Musiek FE, Luxon LM. Aetiology and clinical presentations of auditory processing disorders – a review. Arch Dis Child 2001; 85(5):361-5.
3. Amos NE, Humes LE. SCAN test-retest reliability for first and third grade children. J Speech Lang Hear Res 1998; 41(4):834-45.
4. Domitz DM, Schow RL. A new CAPD battery – multiple processing assessment: factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2):101-11.
5. Task Force on Central Auditory Processing Consensus Development. American Speech-Language-Hearing Association. Central auditory processing: Current status of research and implications for clinical practice. Am J Audiol 1996; 5:41-54.
6. Jerger J, Musiek F. Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000; 11(9):467-74.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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