REVIEW REQUEST FOR
Bone Anchored and Bone Conduction Hearing Aids
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00020
Policy Last Review Date: 08/06/2015 Policy Effective Date: 10/06/2015 Provider Tool Effective Date: 10/06/2015
Individual’s Name:
Insurance Identification Number:
Date of Birth:
Individual’sPhone Number:
Provider ID Number: Ordering Provider Name & Specialty:
Office Address:
Office Phone Number: Office Fax Number:
Rendering Provider Name & Specialty:
Office Address:
Office Phone Number:
Provider ID Number:
Office Fax Number:
Facility Name:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Facility ID Number:
Place of Service: Home Inpatient
Outpatient Other:
Diagnosis Code(s) (if known):
This medical policy base data collection tool is for a medical necessity request for implantable bone-anchored hearing aids, transcutaneously worn, non-surgical application of a bone-anchored hearing aid using headband or
Softband, partially implantable magnetic bone conduction hearing aids, and an intraoral bone conduction hearing aid as an alternative to an air conduction hearing aid in the treatment of moderate-to-severe hearing loss (HL) or to improve speech recognition in individuals with unilateral sensorineural hearing loss (also referred to as single sided deafness).
Carefully select your request and complete the form as appropriate for the individual
Device Requested
Request is for an implantable bone-anchored hearing aid as an alternative to an air conduction hearing aid
Individual is5years of age or older
Request is for a transcutaneously worn non-surgical application of an implantable bone-anchored hearing aid
(bone conduction – type hearing aid) utilizing a Headband or Softband as an alternative to an implanted bone anchored hearing aid or air conduction hearing aid
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REVIEW REQUEST FOR
Bone Anchored and Bone Conduction Hearing Aids
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00020
Policy Last Review Date: 08/06/2015 Policy Effective Date: 10/06/2015 Provider Tool Effective Date: 10/06/2015
Medical condition
Check all that apply to the individual:
Individual has congenital or surgically induced ear malformations of the external or middle ear canal
(e.g., atresia)
Individual has severe chronic external otitis or otitis media
Individual has tumors of the external ear canal or tymapanic cavity
Individual has dermatitis of the external ear canal, including reactions from ear molds used in air conduction
hearing aids
Individual has other anatomic or medical conditions that contraindicate the use of an air conduction hearing aid
Please list the condition:
Audiologic condition
Request is for a bilateral implant in an individual with moderate to severe bilateral symmetric bone conductive or mixed (conductive & sensorineural) hearing loss (If checked, complete below)
Symmetric bone conduction threshold is less than 10 dB average difference between ears (measured at
0.5, 1, 2, and 4 kHz), orless than a 15 dB difference at individual frequencies (BAHA Divino™ , Ponto™
Plus, Ponto Plus Power)
Symmetric bone conduction threshold is less than 10 dB average difference between ears (measured at
0.5, 1, 2, and 3 kHz)(4kHz for OBC and Ponto Pro), orless than a 15 dB difference at individual frequencies (BAHA Cordelle II; BAHA BP 100; BAHA Intenso™)
Other (please list)
Request is for a unilateral implant in an individual with conductive or mixed (conductive & sensorineural) hearing loss(If checked, complete below)
Pure tone average (PTA) bone conduction threshold(measured at 0.5, 1, 2, and 3 kHz) of lessthan or equal to 45 dB (BAHA Divino; BAHA BP 100Systems, OBC, Ponto Plus)
Pure tone average (PTA) bone conduction threshold better than or equal to 55 dB (BAHA
IntensoPonto Plus Power)
Pure tone average (PTA) bone conduction threshold better than or equal to 65 dB (BAHA
Cordelle II)
Other (please list)
Request for device is to improve speech recognition in an individual 5 years of age or older with unilateral sensorineural hearingloss (that is, single sided deafness) and has normal hearing in the other ear.
(If checked, complete below)
Pure tone average(PTA) air conductionthreshold of the non-affected ear isless than or equal to20 dBsat 0.5, 1, 2, and3 kHz
Other (please list)
Other (please list)
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REVIEW REQUEST FOR
Bone Anchored and Bone Conduction Hearing Aids
Provider Data Collection Tool Based on Anthem Medical Policy SURG.00020
Policy Last Review Date: 08/06/2015 Policy Effective Date: 10/06/2015 Provider Tool Effective Date: 10/06/2015
Note: Above criteria must also be completed when requesting replacement parts / upgrades
Request is for replacement parts or upgrades to existing bone-anchored hearing aid components
(Please complete below)
Batteries
Processor
Headband or Softband
Other (please list)
Replacement parts / upgrades are requested because the response to existing components is inadequate to
the point of interfering with activities of daily living
Replacement parts / upgrades are requested because components are no longer functional
Replacement parts / upgrades are requested for convenience or to upgrade to newer technology when current
components remain functional
Other (please list)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
Name and Title of Provider or Provider Representative Completing
Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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