Cal. Code Regs. Tit. 22, § 51319 - Hearing Aids

(a) Hearing aids are covered only when supplied by a hearing aid dispenser on prescription of an otolaryngologist, or the attending physician where there is no otolaryngologist available in the community, plus an audiological evaluation including a hearing aid evaluation which must be performed by or under the supervision of the above physician or by a licensed audiologist.

(b) Prior to prescribing a hearing aid, the otolaryngologist or attending physician shall perform a complete ear, nose and throat examination.

(c) Prior authorization is required for the purchase or trial period rental of hearing aids, and for hearing aid repairs which exceed a cost of $25.00 per repair service. Claims for individual repair services shall not be cumulative for the purposes of determining the need for prior authorization.

(1) Ear molds are covered without prior authorization.

(2) Prior authorization is required for all supplies and accessories necessary for the operation of a hearing aid, except as provided in (1) above.

(3) Binaural hearing aids may be authorized under any of the following conditions:

(A) The hearing loss is associated with legal blindness.

(B) For beneficiaries 20 years of age or under, tests of each ear reveal a hearing loss level of 30 dB or greater, American National Standards Institute (ANSI), 1969, for 500, 1,000, and 2,000 Hertz (Hz) by pure tone air conduction. Cases shall be referred to California Children Services for evaluation, consultation, or case management for patients eligible for such coverage by California Children Services.

(C) For beneficiaries over 18 years of age, tests of each ear reveal a hearing loss level of 35 dB or greater, ANSI, 1969 for 500, 1,000, and 2,000 Hertz (Hz) by pure tone air conduction. Where the provision of a binaural hearing aid is the basis for employment, beneficiaries with the above hearing loss shall be referred to the California Department of Rehabilitation for evaluation, consultation, and case management as provided in Section 51014.

(d) Requests for authorization for hearing aids must include the results of the following tests:

(1) Pure tone air conduction threshold and bone conduction tests of each ear at 500, 1,000, 2,000, 3,000 and 4,000 Hertz (Hz) with effective masking as indicated.

(2) Speech tests, aided and unaided, shall include the following:

(A) Speech Reception Threshold (SRT) using Spondee words.

(B) A Word Discrimination Score (WDS) derived from testing at 40 decibels (dB) above the SRT or at the Most Comfortable Loudness (MCL) using standard discrimination word lists (such as PB or W22) utilizing either recorded or live voice.

(C) Sound Field Aided and Unaided, Speech Scores (SRT and WDS) shall be established.

(e) Test results shall be presented in a format acceptable to the Medi-Cal consultant and shall include proposed hearing aid specifications.

(f) Authorization for hearing aids may be granted only when:

(1) Tests of the better ear, after treatment of any condition contributing to the hearing loss, reveal an average hearing loss level of 35 dB or greater, ANSI, 1969, for 500, 1000, and 2000 Hertz (Hz) by pure tone air conduction, or:

(2) The difference between the level of 1000 Hertz (Hz) and 2000 Hrtz (Hz) is 20 dB or more, the average of the air conduction threshold at 500, 1000, and 2,000 Hertz (Hz) need only be 30 dB hearing level, (ANSI, 1969), and

(3) Speech communication is effectively improved or auditory contact is necessary for sound awareness (personal safety) in the environment in which the beneficiary exists.

(g) Replacement of a hearing aid may be authorized only if:

(1) The prior hearing aid has been lost, stolen, or irreparably damaged due to circumstances beyond the beneficiary's control. The Treatment Authorization Request shall include each of the following:

(A) A statement describing the circumstances of the loss, theft, or destruction of the hearing aid, signed by the beneficiary and the otolaryngologist or the attending physician if there is no otolaryngologist available in the community.

(B) An audiological evaluation, if other than a duplicate of the prior hearing aid is required.

(2) The hearing impairment of the beneficiary requires amplification or correction not within the capabilities of the beneficiary's present hearing aid. The new aid shall be prescribed in accordance with (a) above.

(h) Eyeglass hearing aids are covered when the requirements of this section and Section 51317 are met at the same time.

(i) Initial hearing aid batteries supplied with the hearing aid are covered when supplied with a hearing aid that has been prior authorized. Replacement hearing aid batteries are not covered.

Notes

Cal. Code Regs. Tit. 22, § 51319

1. New subsection (g) filed 1-18-74; effective thirtieth day thereafter (Register 74, No. 3). For prior history, see Register 72, No. 40.
2. Amendment of subsection (f) filed 5-15-79 as an emergency; designated effective 5-15-79 (Register 79, No. 20).
3. Editorial correction (Register 79, No. 26).
4. Certificate of Compliance filed 9-12-79 (Register 79, No. 37).
5. Amendment filed 9-4-80; effective thirtieth day thereafter (Register 80, No. 36).
6. Editorial correction of subsection (f)(2) (Register 80, No. 40).
7. Amendment of subsection (c)(1) and new subsection (h) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
8. Certificate of Compliance transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
9. Amendment of subsection (h) filed 3-1-84; effective thirtieth day thereafter (Register 84, No. 9).
10. Amendment filed 6-22-87; operative 7-22-87 (Register 87, No. 27).
11. Amendment of subsection (c)(1), new subsection (c)(2) and subsection renumbering filed 4-4-2003 as an emergency; operative 4-4-2003 (Register 2003, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-4-2003 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 4-4-2003 order transmitted to OAL 7-28-2003 and filed 9-4-2003 (Register 2003, No. 36).

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code; and Section 57(c), Chapter 328, Statutes of 1982. Reference: Sections 14053, 14132 and 14133, Welfare and Institutions Code; and Section 53, Chapter 328, Statutes of 1982.

1. New subsection (g) filed 1-18-74; effective thirtieth day thereafter (Register 74, No. 3). For prior history, see Register 72, No. 40.
2. Amendment of subsection (f) filed 5-15-79 as an emergency; designated effective 5-15-79 (Register 79, No. 20).
3. Editorial correction (Register 79, No. 26).
4. Certificate of Compliance filed 9-12-79 (Register 79, No. 37).
5. Amendment filed 9-4-80; effective thirtieth day thereafter (Register 80, No. 36).
6. Editorial correction of subsection (f)(2) (Register 80, No. 40).
7. Amendment of subsection (c)(1) and new subsection (h) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
8. Certificate of Compliance transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
9. Amendment of subsection (h) filed 3-1-84; effective thirtieth day thereafter (Register 84, No. 9).
10. Amendment filed 6-22-87; operative 7-22-87 (Register 87, No. 27).
11. Amendment of subsection (c)(1), new subsection (c)(2) and subsection renumbering filed 4-4-2003 as an emergency; operative 4-4-2003 (Register 2003, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-4-2003 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 4-4-2003 order transmitted to OAL 7-28-2003 and filed 9-4-2003 (Register 2003, No. 36).