Clarifying the Blue Cross Blue Shield Federal Employee Program (BCBS FEP) Hearing Aid Policy

March 8, 2024

Update: April 2024

In March 2024, ASHA submitted guidance and research to the Blue Cross Blue Shield Federal Employee Program (BCBS FEP) that outlined our concerns with the program’s prior approval process and hearing aid device policy. BCBS FEP reviewed our guidance and responded to our requests. It released an updated UM Guideline 005 Hearing Aid [PDF] effective April 1, 2024. Although hearing aids will still require prior authorization, the policy update includes a change to their medical necessity guidelines.

The guidelines previously stated that medical necessity required a hearing loss over 40 decibels (dB) with opportunities for individual review for hearing loss of 40 dB or less. The policy now indicates medical necessity for hearing aids requires that:

“The degree of hearing loss is confirmed by audiometry or other age-appropriate testing to be greater than 26 dB hearing loss (HL) for: a. conductive hearing loss unresponsive to medical or surgical interventions b. sensorineural hearing loss c. mixed hearing loss (combination of conduction hearing loss and sensorineural hearing loss).”

ASHA has repeatedly requested that BCBS FEP revise the inaccurate statement in its policy that declares ASHA defines the degree of hearing loss based on pure tone average. We are continuing to follow up to ensure BCBS FEP re-reviews the misquoted ASHA guideline related to determining threshold level for speech.

March 2024

ASHA is tracking and addressing issues that have stemmed from the most recent Blue Cross Blue Shield Federal Employee Program UM Guideline 005 on Hearing Aids [PDF]. The updated guideline indicated a new requirement for prior approval and changed the previous medical necessity criteria for obtaining air conduction hearing aids. This resulted in inconsistent interpretations and inappropriate denials for medically necessary hearing aids among BCBS FEP programs across the country.

ASHA and other stakeholders each reached out to the national BCBS FEP, which has since clarified that the guideline only applies to adult air conduction hearing aids and coverage should be individually considered for hearing loss of 40 dB or less.

Ongoing Issues With Denials and Prior Approval Processes

While the updated guideline indicates coverage is considered medically necessary when a patient’s hearing loss is above 40dB, it also states that “consideration should be given on an individual basis, for hearing loss of 40 decibels or less with a prescription from a licensed healthcare provider.”

Despite this clarification, BCBS FEP administrators across the country are still inconsistently implementing the updated policy and not providing clear guidance on the new process. Unfortunately, that means audiologists are continuing to experience automatic denials for hearing aids when a patient’s hearing loss is 40 dB or less without appropriate individual review. There is also a concerning lack of information on prior approval protocol from each BCBS FEP administrator, leaving audiologists scrambling to figure out how they can quickly and efficiently help their clients.

ASHA has sent a letter and continues to press the national BCBS FEP [PDF] to clarify the nuances of the hearing aid policy to all BCBS companies administering FEPs nationwide. We are also seeking support from the federal government’s Office of Personnel Management (OPM) to ensure that the BCBS FEP UM guideline is appropriately implemented across the country.

What ASHA Is Doing

In our communications to BCBS and OPM, ASHA expressed concern regarding the prior approval process and limited parameters for obtaining hearing aid devices. When relevant, other factors must be considered to determine medical necessity including – but not limited to – speech intelligibility index, patient reported outcomes, speech-in-noise testing, and cognition. To reinforce this, we provided carefully selected research and guidance supporting hearing aid prescriptions for hearing loss of 40 dB or less for BCBS and OPM’s review as well.

ASHA Advocacy staff will continue to encourage reconsideration of medical necessity parameters and work with BCBS and OPM to ensure the coverage guidelines and prior approval processes do not pose an unnecessary barrier to care for FEP beneficiaries.

What Audiologists Can Do

Here are some steps you can take in the meantime to obtain approval for medically necessary air conduction hearing aids under BCBS FEP.

Work directly with your local BCBS FEP administrator

Hearing aids now require prior approval, but the process can vary depending on your local BCBS company. Check directly with your local BCBS to determine what needs to be submitted for their prior approval process. Contact information should be available on the patient's insurance card, or they can check with their employer.

Include documentation of functional need

When submitting documentation for prior approval, be sure to include information on the functional need for the patient to obtain a hearing aid beyond their dB loss. Include any relevant test results to support your recommendations. The appeal letter linked below offers guidance on what to consider including that supports medical necessity.

Submit an appeal

If the initial request for the hearing aid is denied, you can submit an appeal to your local BCBS company according to its appeals process. We have developed guidance on submitting an appeal and a customizable template letter [DOC] that you can use to assist with the appeal process.

Dispute multiple denials with OPM

If you have fully exhausted your local BCBS’s appeal process, you can submit a claims dispute directly with OPM. OPM offers guidance on how to submit a disputed claim to its office.