Sec. 10.09.51.05. Limitations

A. Covered audiology services, including hearing aids, cochlear implants, and auditory osseointegrated devices are limited to:

(1) Unless the time limitation is waived by the Program, one audiology assessment per year;

(2) The initial coverage of unilateral or bilateral hearing aids, cochlear implants, or auditory osseointegrated devices when the Department’s medical necessity criteria have been met;

(3) Replacement of unilateral or bilateral hearing aids once every 5 years unless the Program approves more frequent replacement;

(4) Replacement of hearing aids, cochlear implants and auditory osseointegrated device components that have been lost, stolen, or damaged beyond repair, after all warranties have expired;

(5) Repairs and replacements that take place after all warranties have expired;

(6) A maximum of 76 batteries per participant per 12-month period for a unilateral hearing aid or osseointegrated devices, or 152 batteries per participant per 12-month period for bilateral hearing aids or osseointegrated devices purchased from the Department not more frequently than every 6 months, and in quantities of 38 or fewer for a unilateral hearing aid, or 76 or fewer for a bilateral hearing aid;

(7) A maximum of 238 disposable batteries for a unilateral cochlear implant per participant per 12-month period or 476 disposable batteries per 12-month period for a bilateral cochlear implant purchased not more frequently than every 6 months, and in quantities of 119 or fewer for a unilateral cochlear implant, or 238 or fewer for a bilateral cochlear implant;

(8) Four replacement cochlear implant component rechargeable batteries per 12-month period for bilateral cochlear implants, and a maximum of two replacement rechargeable batteries for a unilateral cochlear implant per 12-month period;

(9) Two cochlear implant replacement transmitter cables per 12-month period for bilateral cochlear implants, and a maximum of one replacement transmitter cable for a unilateral cochlear implant per 12-month period;

(10) Two cochlear implant replacement headset cables per 12-month period for bilateral cochlear implants, and a maximum of one replacement headset cable for a unilateral cochlear implant per 12-month period;

(11) Two replacement cochlear implant transmitting coils per 12-month period for bilateral cochlear implants, and a maximum of one replacement transmitting coil for a unilateral cochlear implant per 12-month period;

(12) Charges for routine follow-ups and adjustments which occur more than 60 days after the dispensing of a new hearing aid; and

(13) A maximum of two unilateral earmolds or four bilateral earmolds per 12-month period unless a larger number is determined to be medically necessary.

B. Services which are not covered are:

(1) Services not medically necessary;

(2) Hearing aids and accessories not medically necessary;

(3) Cochlear implant services and external components not medically necessary;

(4) Cochlear implant services and external components provided less than 90 days after the surgery which are covered through the initial reimbursement;

(5) Spare or backup cochlear implant components;

(6) Spare or back-up auditory osseointegrated device components;

(7) Replacement of hearing aids, equipment, cochlear implant components, and auditory osseointegrated device components if the existing devices are functional, repairable, and appropriately correct or ameliorate the problem or condition;

(8) Spare or backup hearing aids, equipment, or supplies;

(9) Repairs to spare or backup hearing aids, cochlear implants, auditory osseointegrated devices, equipment, or supplies;

(10) Investigational or experimental services or devices, or both;

(11) Replacement of improperly fitted earmold or earmolds unless the:

(a) Replacement service is administered by someone other than the original provider; and

(b) Replacement service has not been claimed before;

(12) Additional professional fees and overhead charges for a new hearing aid when a dispensing fee claim has been made to the Program; and

(13) Loaner hearing aids.