Aural Rehabilitation

Number: 0034

Policy

Scope of Policy

This Clinical Policy Bulletin addresses Aural Rehabilitation.

  1. Medical Necessity

    Aetna considers aural rehabilitation medically necessary as speech therapy for members with hearing impairments and after placement of a cochlear implant.

    Aetna considers aural rehabilitation not medically necessary for cochlear implant users who have reached a plateau in performance.

  2. Experimental and Investigational

    Aetna considers aural rehabilitation experimental and investigation for individuals with hearing loss and without a cochlear implant and for the treatment of tinnitus because of insufficient evidence of this approach.

  3. Related Policies

Background

An aural rehabilitation program generally starts as soon as a patient is identified as having a hearing impairment, or after placement of a cochlear implant.  The patient is taught to speak, to adjust to a hearing aid or cochlear implant, and to look to a speaker's mouth and face to better comprehend what is being said.  The parent or other caregiver is taught to treat the patient normally, to talk to the patient, and interact with him/her as though there were no impairment.  The rehabilitation program following implantation of a cochlear implant usually consists of 6 to 10 sessions that last approximately 2.5 hours each.

Hearing Loss and Without a Cochlear Implant

Michaud and Duchesne (2017) stated that few systematic reviews have been conducted regarding aural rehabilitation for adults with hearing loss, with none specifically targeting the older adult population.  These researchers stated that with prevalence rates of hearing loss being highest in older adults, examining the effects of aural rehabilitation on this population is needed.  They evaluated the effects of aural rehabilitation on quality of life (QOL) in an older adult population presenting with hearing loss.  Studies with adults presenting with hearing loss, greater than or equal to 50 years of age, with or without hearing aids, receiving interventions such as auditory training, speech-reading, communication strategies training, speech tracking, counseling, or a combination of approaches, and measuring outcomes related to QOL, in an individual or group format, with or without significant others and with no limitations as to year of publication were selected for analysis.  These investigators performed searches in 6 databases, as well as results from hand-searching, gray literature, and cross-referencing of articles, and retrieved 386 articles.  Of the 145 assessed as full-text articles for eligibility, 8 studies met inclusion criteria.  A component-based risk of bias assessment, as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adopted.  No effect sizes were found in group interventions measuring outcomes related to QOL, such as mental and emotional functions, environmental factors, participation restrictions, and activity limitations.  An intervention effect regarding participation was found for a self-administered home training program, but an effect size was unavailable.  Small-to-medium effect sizes were found in 1 of 2 individual communication training programs, for which outcomes related to QOL, such as emotional functions, activities, participation, and environmental factors were measured.  The results of the component-based risk of bias assessment indicated that the quality of reporting was poor, thus compromising the internal validity of included primary studies.  The authors concluded that these findings indicated that the combined body of evidence in support of aural rehabilitation for older adults with hearing loss was insufficient to draw any firm conclusions; they identified a need for more rigorous research to guide clinical decision-making.

Aural Rehabilitation for Tinnitus

Searchfield and associates (2018) stated that tinnitus is a common otoneurological complaint often accompanying hearing loss.  In this perspective on rehabilitation, these investigators described a framework for sound therapy and aural rehabilitation of tinnitus based on the ecological model of tinnitus.  A thematic network analysis-based approach was used to relate aural rehabilitation methods to the ecological model of tinnitus and the client-oriented scale of improvement in tinnitus.  Aural rehabilitation methods were mapped to concepts of context, presence of sound, and reaction to sound.  A global theme was: adaptation to sound.  The framework was the result of an iterative and cumulative research program exploring tinnitus as the outcome of the relationship between individual psycho-acoustics and psycho-social factors including context of perception.  The authors concluded that the intent of this framework was to help guide audiologists managing tinnitus.  The framework has been useful in the authors’ clinic as illustrated by a case study.  They stated that the benefits of this approach relative to standard care needs to be independently ascertained.

Cochlear Implant Users Who Have Plateaued in Performance

Moberly and colleagues (2018) stated that for experienced adult cochlear implant (CI) users who have reached a plateau in performance, a clinician-guided aural rehabilitation (CGAR) approach can improve speech recognition and hearing-related QOL.  These researchers proposed that CGAR could improve speech recognition and hearing-related QOL in experienced CI users.  A total of 12 adult CI users were enrolled in an 8-week CGAR program guided by a speech-language pathologist and audiologist; 9 patients completed the program along with pre-AR and immediate post-AR testing of speech recognition (AzBio sentences in quiet and in multi-talker babble, consonant-nucleus-consonant words in quiet), QOL (Nijmegen Cochlear Implant Questionnaire, Hearing Handicap Inventory for Adults/Elderly, and Speech, Spatial and Qualities of Hearing Scale), and neurocognitive functioning (working memory capacity, information-processing speed, inhibitory control, speed of lexical/phonological access, and nonverbal reasoning).  Pilot data for these 9 patients were presented.  From pre-CGAR to post-CGAR, group mean improvements in word recognition were found.  Improvements were also demonstrated on some composite and sub-scale measures of QOL.  Patients who demonstrated improvements in word recognition were those who performed most poorly at baseline.  The authors concluded that CGAR represents a potentially effective approach to improving speech recognition and QOL for experienced CI users.  These investigators also discussed limitations and considerations in implementing and studying aural rehabilitation approaches.

These researchers stated that early results were encouraging, and a number of limitations and considerations of AR research approaches have been identified that are worth discussing for future designs of AR studies.  They stated that this approach deserved further development and exploration to optimize adult CI outcomes.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:
92626 Evaluation of auditory rehabilitation status; first hour
+ 92627     each additional 15 minutes
92630 Auditory rehabilitation; pre-lingual hearing loss
92633     post-lingual hearing loss

Other CPT codes related to the CPB:
69930 Cochlear device implantation, with or without mastoidectomy

Other HCPCS codes related to the CPB:
L8614 - L8624 Cochlear device/system/supplies

ICD-10 codes covered if selection criteria are met:
H74.01 - H74.93 Other disorders of middle ear mastoid
H80.00 - H80.93 Otosclerosis
H81.01 - H81.09 Meniere's disease
H90.0 - H90.8 Conductive and sensorineural hearing loss
H93.011 - H93.099, H93.211 - H93.93 Other disorders of ear, not elsewhere classified
Z96.21 Cochlear implant status

ICD-10 codes not covered for indications listed in the CPB:
H93.11 - H93.19, H93.A1 - H93.A9 Tinnitus

The above policy is based on the following references:

  1. American Speech-Language-Hearing Association (ASHA). Aural rehabilitation. Information for the Public. Rockville, MD: ASHA; 2004. Available at: http://www.asha.org/public/hearing/treatment/gen_aur_rehab.htm. Accessed January 22, 2004.
  2. Boothroyd A. Adult aural rehabilitation: What is it and does it work? Trends Amplif. 2007;11(2):63-71.
  3. Danermark BD. Hearing impairment, emotions and audiological rehabilitation: A sociological perspective. Scand Audiol Suppl. 1998;49:125-131.
  4. Hawkins DB. Effectiveness of counseling-based adult group aural rehabilitation programs: A systematic review of the evidence. J Am Acad Audiol. 2005;16(7):485-493.
  5. Jankowski R, Pialoux R, Labaeye P, et al. Bone anchored hearing aid (BAHA): Clinical evaluation. Ann Otolaryngol Chir Cervicofac. 1998;115(6):315-320.
  6. Karlsson AK, Rosenhall U. Aural rehabilitation in the elderly: Supply of hearing aids related to measured need and self-assessed hearing problems. Scand Audiol. 1998;27(3):153-160.
  7. Lantsov AA, Koroleva IV, Pudov VI. Rehabilitation and assessment of aural-oral speech development in children with cochlear implants. Vestn Otorinolaringol. 2000;(3):6-12.
  8. Li J, Xi X, Hong M, et al. Study of aural rehabilitation in post-lingual deafened patients with multi-channel cochlear implant. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2010;24(13):580-582.
  9. Malmberg M, Sundewall Thoren E, Oberg M, et al. Experiences of an Internet-based aural rehabilitation (IAR) program for hearing aid users: A qualitative study. Int J Audiol. 2018;57(8):570-576.
  10. Michaud HN, Duchesne L. Aural rehabilitation for older adults with hearing loss: Impacts on quality of life -- A systematic review of randomized controlled trials. J Am Acad Audiol. 2017;28(7):596-609.
  11. Moberly AC, Vasil K, Baxter J, Ray C. What to do when cochlear implant users plateau in performance: A pilot study of clinician-guided aural rehabilitation. Otol Neurotol. 2018;39(9):e794-e802.
  12. Qiu WW, Yin S, Stucker FJ. Critical evaluation of deafness. Auris Nasus Larynx. 1999;26(3):269-276.
  13. Searchfield GD, Linford T, Durai M. Sound therapy and aural rehabilitation for tinnitus: A person centred therapy framework based on an ecological model of tinnitus. Disabil Rehabil. 2018:1-8.
  14. Sweetow RW, Sabes JH. Technologic advances in aural rehabilitation: Applications and innovative methods of service delivery. Trends Amplif. 2007;11(2):101-111.
  15. Sykes S, Tucker D, Herr D. Aural rehabilitation and graduate audiology programs. J Am Acad Audiol. 1997;8(5):314-321.
  16. Tobey EA, Devous MD Sr, Buckley K, et al. Pharmacological enhancement of aural habilitation in adult cochlear implant users. Ear Hear. 2005;26(4 Suppl):45S-56S.
  17. Tomaski SM, Grundfast KM. A stepwise approach to the diagnosis and treatment of hereditary hearing loss. Pediatr Clin North Am. 1999;46(1):35-48.
  18. van Besouw RM, Nicholls DR, Oliver BR, et al. Aural rehabilitation through music workshops for cochlear implant users. J Am Acad Audiol. 2014;25(4):311-323.
  19. Wazen JJ, Wright R, Hatfield RB, et al. Auricular rehabilitation with bone-anchored titanium implants. Laryngoscope. 1999;109(4):523-527.