BlueCross BlueShield of Tennessee Medical Policy Manual

Conditioning Play Audiometry for Hearing

DESCRIPTION

Conditioning play audiometry (CPA) is a type of audiometric study used as a diagnostic test to evaluate hearing loss. CPA is a standard battery test that is considered to be part of the initial work-up for children, age two (2) to four (4) years of age with hearing impairment. It is a form of instrumental/operant conditioning in which a child is taught to wait and listen for a stimulus. The child is then to respond by performing a motor task in response to the stimulus. For example, the child is taught to put an object in a specific place, (e.g., a marble in a box or a cow in the barnyard) when a specific sound is heard.

POLICY

• Conditioning play audiometry for the diagnosis and evaluation of hearing impairment is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

See also:

• Evoked Otoacoustic Emissions

• General Policy on Hearing Impairment

• Pure-Tone Audiometry

MEDICAL APPROPRIATENESS

• Conditioning play audiometry for the diagnosis and evaluation of hearing impairment is considered medically appropriate if ALL of the following criteria are met:

• • The child is age two to four (2 - 4)

  • The child has no other developmental or physical impairment

  • ANY ONE of the following conditions exist:

  • • Bacterial meningitis

    • Cochlear otosclerosis

    • Congenital anomalies

    • Exposure to intense noise

    • Facial nerve paralysis (Bell's Palsy)

    • Fractures of the temporal bone or trauma affecting the central auditory pathways

    • Hearing loss

    • Labyrinthitis

    • Ménière's disease

    • Neoplasms of the auditory or central nervous system

    • Otitis media

    • Ototoxic drugs

    • Surgery involving the auditory and/or central nervous system (e.g., skull-based tumors such as acoustic neuroma and meningioma)

    • Tinnitus

    • Vertigo (dizziness)

IMPORTANT REMINDERS

• Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.

• We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

SOURCES

American Academy of Otolaryngology-Head and Neck Surgery. (2011, April). Children’s hearing health. Retrieved November 18, 2011 from http://www.entnet.org/HealthInformation/childshearing.cfm.

American Academy of Pediatrics. (2009). Clinical report - Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 124 (4), p. 1252-1263.

American Speech and Language Association. (2004). Guidelines for the audiologic assessment of children from birth to 5 years of age. Retrieved December 3, 2008 from http://search.asha.org/query.html?col=asha&col=ashfoun&col=nsslha&qt=guidelines%20for%20audiologic%20screening.

American Speech-Language-Hearing Association. (2011). Pure-Tone Testing. Retrieved November 17, 2011 from http://www.asha.org/public/hearing/Pure-Tone-Testing/.

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2005). Evaluation of hearing impairment (9.01.02). Retrieved November 18, 2011 from BlueWeb. (6 articles and/or guidelines reviewed)

Code of Federal Regulations (CFR) 45 C.F.R. § 1308.21- Subpart G--Parent Involvement Performance Standards. October 2007. P. 170-186. Retrieved December 4, 2008 from http://frwebgate1.access.gpo.gov/cgi-bin/PDFgate.cgi?WAISdocID=40143522876+79+2+0&WAISaction=retrieve.

U. S. Preventive Services Task Force. (2008). Universal screening for hearing loss in newborns. Retrieved November 17, 2011 from http://www.uspreventiveservicestaskforce.org/uspstf08/newbornhear/newbhearrs.htm.

ORIGINAL EFFECTIVE DATE:  10/1998

MOST RECENT REVIEW DATE:  1/12/2012  

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.