Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder Product Applicability

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Medical Policy

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Policy Number: OCA 3.82 Version Number: 17 Version Effective Date: 01/01/21

Product Applicability All Plan+ Products

Well Sense Health Plan ∆ Boston Medical Center HealthNet Plan ∆ Well Sense Health Plan MassHealth ACO MassHealth MCO Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options

Notes: + Disclaimer and audit information is located at the end of this document. ∆ As required by state regulations and/or benefit coverage, different Plan definitions are specified for BMC HealthNet Plan products and Well Sense Health Plan products. See the applicable Definitions section for the Plan member.

Policy Summary The evaluation of central auditory functioning to diagnose central auditory processing disorder (CAPD) is considered medically necessary for an adult or pediatric member when applicable Plan criteria are met. The evaluation is medically necessary when it is not part of a member’s individualized education plan (IEP) when one is appropriate for the member, it is a covered benefit for the member, and the Plan’s medical criteria are met (as specified in the Medical Policy Statement section of this Plan policy). Prior authorization is required for Plan covered services. See the member’s applicable benefit document available at www.bmchp.org for a member enrolled in a BMC HealthNet Plan product or

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 18

www.wellsense.org for a member enrolled in a Well Sense Health Plan product. The Plan will coordinate medically necessary services with school-based services, whenever possible.

It will be determined during the Plan’s prior authorization process if the evaluation is considered medically necessary for the requested indication. See the Plan’s Medically Necessary medical policy, policy number OCA 3.14, for the product-specific definitions of medically necessary treatment. Review the Plan’s Autism Spectrum Disorders Medical Diagnosis and Treatment medical policy, policy number OCA 3.724, for clinical criteria and prior authorization requirements for medically necessary autism- associated services.

Description of Item or Service Central Auditory Processing Evaluation to Diagnose Central Auditory Processing Disorder (CAPD)/Auditory Processing Disorder (APD): Series of tests used to evaluate central auditory function and diagnose CAPD for an individual. Test results are used to describe the nature and extent of the disorder for purposes of developing management and intervention programs for affected individuals. There are two (2) major categories of tests: (1) behavioral tests and (2) electrophysiologic tests (using a single stimulus or multiple stimuli in one or both ears). The provider selects the appropriate battery of central auditory function tests after evaluating the patient with routine hearing tests. Central auditory function tests are used to differentiate central from peripheral hearing loss and occasionally to identify the site of a lesion in the central nervous system.

Medical Policy Statement The evaluation of a member’s central auditory function to diagnose central auditory processing disorder (CAPD) is considered medically necessary when the following applicable criteria are met and documented in the member’s medical record (even when prior authorization is not required). Prior authorization may or may not be required based on the frequency of the evaluation, as specified below in item A and item B.

A. Prior Authorization is REQUIRED:

Prior authorization is REQUIRED for an evaluation when another evaluation for central auditory function occurred within the last 12 consecutive calendar months from the requested date of service (by any treating provider). ALL of the following criteria must be met, as specified below in items 1 through 8:

1. Standard audiometry test results have been normal; AND

2. The member is 7 years of age or older on the date of service; AND

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

3. The member’s behavioral characteristics include at least ONE (1) of the following, as specified below in items a through o:

a. Difficulty localizing sound; OR

b. Difficulty understanding spoken language in competing messages, noisy backgrounds, or in reverberant environments; OR

c. Taking longer to respond in oral communication situations; OR

d. Frequent requests for repetitions such as saying “what” and “huh” frequently; OR

e. Inconsistent or inappropriate responding; OR

f. Difficulty comprehending and following rapid speech; OR

g. Difficulty following complex auditory directions or commands; OR

h. Difficulty learning songs or nursery rhymes; OR

i. Misunderstanding messages, such as detecting prosody changes that help to interpret sarcasm or jokes; OR

j. Poor musical and singing skills; OR

k. Difficulty paying attention; OR

l. Being easily distracted; OR

m. Poor performance on speech and language or psychoeducational tests in the areas of auditory-related skills; OR

n. Associated reading, spelling, and learning problems; OR

o. Difficulty learning a new language; AND

4. For members between the ages of 7 and 21 on the date of service, the evaluation of CAPD is NOT included as part of the member’s individual education plan (IEP) OR if the school district’s decision has been appealed and the appeal has been turned down, if applicable; AND

5. An independent professional (i.e., audiologist, pediatrician, psychologist, psychiatrist) has concluded that this testing is still required to enhance the child’s education; AND

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

6. The evaluation of CAPD is necessary to improve the member’s health and functioning outside of the school or work environment; AND

7. The service is covered for the member, as specified in the Limitations section of this policy and the member’s applicable benefit documents available at www.bmchp.org or www.wellsense.org; AND

8. The member has had a prior evaluation of central auditory function within the last 12 consecutive calendar months from this requested date of service (by any treating provider), but the member has NOT exceeded more than two (2) evaluations for CAPD per lifetime;∞ OR

∞ Note: A Plan member enrolled in a MassHealth product would NOT have a lifetime benefit maximum for this service but would require prior authorization after the member received two (2) evaluations for CAPD.

B. Prior Authorization is NOT required:

Prior authorization is NOT required when ALL of the following criteria are met, as specified below in items 1 through 3:

1. The member has NOT had an evaluation of central auditory functioning in the last 12 consecutive calendar months from the requested date of service (by any treating provider);∞ AND

2. The member has not exceeded the maximum of two (2) evaluations for CAPD per lifetime;∞ AND

3. ALL criteria specified above in items A1 through A8 are met and documented in the member’s medical record (even when prior authorization is NOT required).

Limitations The evaluation of central auditory processing to diagnose CAPD requires Plan Medical Director review and Plan authorization if the member is younger than age 7 on the date of service and/or when applicable medical necessity criteria in the Medical Policy Statement section of this policy are NOT met. Review the member’s appropriate benefit document for guidelines on benefit coverage and limitations (when applicable) available at www.bmchp.org for a BMC HealthNet Plan member and available at www.wellsense.org for a Well Sense Health Plan member.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Definitions for BMC HealthNet Plan Products ∆ Central Auditory Function/Central Auditory Processing (CAP): The efficiency and effectiveness with which the central nervous system utilizes auditory information.

Early Intervention Programs (EIP): As defined by the Massachusetts Department of Public Health (DPH) 2013 Early Intervention Services Operational Standards, EIPs are an integrated developmental service available to children up to age three (3) years old who have developmental concerns due to identified disabilities or whose typical development is at risk due to certain birth or environmental circumstances. The purpose of the DPH-certified services is to provide comprehensive, integrated services to eligible children and their families which are educational, therapeutic, and social in nature. Any individual concerned about a child’s development may refer the child for an evaluation. By law, evaluations must begin within 45 days of a referral.

Individualized Family Services Plan (IFSP): As defined by the Massachusetts Department of Public Health (DPH) 2013 Early Intervention Services, IFSPs are working documents produced for children who qualify for Early Intervention (EI). IFSPs are developed in collaboration with the child’s family and by an EI team that may include speech, occupational and physical therapists, developmental educators, social workers, psychologists, and nurses. In addition, EI teams may also include contracted consultants who specialize in areas such as nutrition, adaptive equipment, and/or behavior management.

Definitions for Well Sense HealthNet Plan Products ∆ Central Auditory Function/Central Auditory Processing (CAP): The efficiency and effectiveness with which the central nervous system utilizes auditory information.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Central Auditory Processing Disorder (CAPD): Also known as auditory processing disorder (APD), auditory perception problem, auditory comprehension deficit, central auditory dysfunction, central deafness and word deafness, CAPD refers to difficulties in the perceptual processing of auditory information (listening skills) in the central nervous system as demonstrated by poor performance in speech perception. The etiology of CAPD may be associated with lesions of the central nervous system, neurological disorder (e.g., brain injury, cerebrovascular disease, exposure to neurotoxins, seizure disorders); neuromaturational delay secondary to deafness/auditory deprivation, otologic disorder, genetic determinants, or the etiology may be unknown.

Early Intervention Programs (EIP): Early Intervention is a nationwide program under Part C of the Individuals with Disabilities Education Act of 2004 (IDEA). Family Centered Early Supports and Services (FCESS) is the New Hampshire (NH) early intervention system. FCESS serves children from birth to age three (3) that have a developmental delay, an established condition, or are at substantial risk for a developmental delay. FCESS is delivered by designated non-profit and specialized service agencies located throughout the state under contract to the NH Department of Health and Human Services Bureau of Developmental Services. FCESS can include ONE (1) or more of the Early Supports and Services (ESS) listed below, as specified in items 1 through 13:

1. Family support, education and counseling;

2. Vision services;

3. Hearing services;

4. Health and nursing services;

5. Medical, diagnostic and evaluation services;

6. Nutrition counseling and assessment;

7. Occupational therapy;

8. Physical therapy;

9. Special equipment;

10. Special instruction;

11. Speech and language therapy;

12. Transportation services; AND/OR

13. Service coordination. Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

The goal of FCESS is to support families in helping their children grow and develop, including helping families achieve their own family goals. Early Support and Services (ESS) are provided in a child’s natural environment (typically the home or child care setting) by qualified professionals such as physical therapists, occupational therapists, speech pathologists, and early childhood developmental specialists. Anyone who has a concern about a child’s development can make a referral to a designated agency. These agencies, responsible for providing EI services, have 45 days to complete an evaluation, determine eligibility and, if the child is eligible, develop an Individualized Family Support Plan (IFSP).

Individualized Education Plan (IEP): In the event that a child qualifies for specially designed education or related services, schools are required to develop an IEP that includes an evaluation and care plan, and also determines an appropriate placement based on the child’s unique needs and disability. Types of assessments may include but are not limited to medical assessments, psychological assessments, home assessments, and/or other assessments as may be required in accordance with a child's diagnosis. According to New Hampshire law RSA 186-C: 29, “Medicaid providers, managed care providers, or private providers receiving full or partial payment through Medicaid shall not require a parent to provide a copy of a child's individualized education program as a prerequisite to determining if a child is eligible for Medicaid-funded services that are not being provided as part of a child's individualized education program.” Managed Care Organizations (MCOs) are allowed to request from schools an accounting of what services are being billed to the State Medicaid Program. It is Well Sense’s expectation that community therapists will, in good faith, coordinate treatment planning with school-based services wherever practicable, in order to minimize duplication of services and increase the overall success of the therapeutic plan.

Individualized Family Services Plan (IFSP): An IFSP is a legal document serving as an agreement between the Family Centered Early Supports and Services (FCESS), the New Hampshire (NH) early intervention system, and the child’s parent(s). IFSPs are developed collaboratively by the child’s family, the Early and Support Services (ESS) Service Coordinator, other therapists/providers who will provide services to the child, and anyone else the parent(s) wish to be involved. Parent(s) signature of the IFSP is required before the FCESS can provide services to the child.

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Since the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

CPT Codes Description: Codes Covered When Medically Necessary 92620 Evaluation of central auditory function, with report; initial 60 minutes 92621 Evaluation of central auditory function, with report; each additional 15 minutes

Clinical Background Information Children and adults with central auditory processing disorder (CAPD) do not recognize subtle differences between sounds and words and have difficulty using auditory information to communicate and learn. The cause of CAPD is often unknown and may be associated with conditions such as dyslexia, attention deficit disorder, autism, autism spectrum disorders, specific language impairments, pervasive developmental disorder, developmental delay, head injury, cerebrovascular accident, and/or dementia. Individuals with CAPD may have ONE (1) or more of the following characteristics, as specified below in items 1 through 8:

1. Trouble paying attention;

2. Problems carrying out instructions with more than one direction;

3. Poor listening skills;

4. Require more time to process information;

5. Low academic performance;

6. Behavior problems;

7. Language difficulty; AND/OR

8. Difficulty with reading, comprehension, spelling, and vocabulary.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

According to the American Academy of Audiology, age is a primary consideration in the evaluation of children. Interpretation of results of behavioral measures of central auditory function in children under age 7 years (developmental age) is difficult; some of the skills a child needs to be evaluated for auditory processing disorder don't develop until the developmental age of 7. While it is more common to screen for CAPD with children, it may also be useful to test adults exhibiting characteristics of CAPD or experiencing hearing complaints that exceed expectations based on pure tone test results and/or do not benefit from amplification with hearing aids, as anticipated; these symptoms may suggest possible central nervous system disease/dysfunction, including head injury, cerebrovascular accident, or dementia. Central auditory nervous system dysfunction is prevalent among older adults and is a component of presbycusis.

CAPD testing represents a challenge because of the wide range of behaviors associated with the disorder. CAPD is an auditory deficit; therefore an audiologist is the type of professional who diagnoses CAPD. The following auditory tests may be included in the evaluation of CAPD by an audiologist, as specified below in item 1 through 7:

1. Auditory discrimination tests;

2. Auditory temporal processing and patterning tests;

3. Dichotic speech tests;

4. Monaural low-redundancy speech tests;

5. Binaural interaction tests;

6. Electroacoustic measures; AND/OR

7. Electrophysiologic measures.

Testing for CAPD may be accepted as a valid diagnostic tool by some practitioners, but there are limitations with testing that do not support it as an evidence-based approach; there are many different series of tests utilized, there is a lack of a gold standard test for comparison, and the overall health impact of CAPD is unknown. According to the National Institute on Deafness and other Communication Disorders (NIDCD), much research is still needed to understand CAPD and the best approaches to any treatment interventions. There are no established or benchmark standard therapies or treatments for individuals who have been diagnosed with CAPD. Several interventions are currently under investigation, but well-designed studies are needed to evaluate these treatment strategies.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

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American Academy of Audiology (AAA). Guidelines and Standards. Central Auditory Processing Disorder (CAPD). Accessed at: https://www.audiology.org/publications/guidelines-and-standards

American Speech-Language-Hearing Association (ASHA). Auditory Integration Training. Position Statement. 2004.

American Speech-Language-Hearing Association (ASHA). Central Auditory Processing Disorders. Overview. Incidence and Prevalence, Signs and Symptoms, Causes, Roles and Responsibilities, Assessment, Treatment, Resources, References. Accessed at: https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589943561§ion=References

American Speech-Language-Hearing Association (ASHA). Position Statement. (Central) Auditory Processing Disorders - The Role of the Audiologist. Working Group on Auditory Processing Disorders. 2005. Accessed at: https://www.asha.org/policy/PS2005-00114/

American Speech-Language-Hearing Association (ASHA). Technical Report. (Central) Auditory Processing Disorders. Working Group on Auditory Processing Disorders. Accessed at: http://www.asha.org/policy/TR2005-00043/

American Speech-Language-Hearing Association (ASHA). Understanding Auditory Processing Disorders in Children. Accessed at: https://www.asha.org/public/hearing/Understanding-Auditory-Processing- Disorders-in-Children/

Atchison SR, Negara NK, Kennett SE, Levi see M. Overview of Central Auditory Processing Deficits in Older Adults. Semen Hear. 2015 Aug; 36(3):150-61. doi: 10.1055/s-0035-1555118. PMID: 27516715.

Barrozo TF, Pagan-Neves Lde O, Vilela N, Carvallo RM, Wertzner HF. The influence of (central) auditory processing disorder in speech sound disorders. Braz J Otorhinolaryngol. 2016 Jan-Feb;82(1):56-64. doi: 10.1016/j.bjorl.2015.01.008. Epub 2015 Oct 20. PMID: 26612604.

Bellis TJ, Bellis JD. Central auditory processing disorders in children and adults. Handb Clin Neurol. 2015;129:537-56. doi: 10.1016/B978-0-444-62630-1.00030-5. PMID: 25726289.

Billiet CR, Bellis TJ. The relationship between brainstem temporal processing and performance on tests of central auditory function in children with reading disorders. J Speech Lang Hear Res. 2011 Feb; 54(1):228-42. doi: 10.1044/1092-4388(2010/09-0239). Epub 2010 Aug 5. PMID: 20689038.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Brenneman L, Cash E, Chermak GD, Guenette L, Masters G, Musiek FE, Brown M, Ceruti J, Fitzegerald K, Geissler K, Gonzalez J, Weihing J. The Relationship between Central Auditory Processing, Language, and Cognition in Children Being Evaluated for Central Auditory Processing Disorder. J Am Acad Audiol. 2017 Sep;28(8):758-69. doi: 10.3766/jaaa.16119.PMID: 28906246.

Centers for Medicare & Medicaid Services (CMS). EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents. 2014 Jun. Accessed at: https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf

Centers for Medicare & Medicaid Services (CMS). Medicaid. Early and Periodic Screening, Diagnosis, and Treatment. Medicaid.gov. Accessed at: https://www.medicaid.gov/medicaid/benefits/epsdt/index.html

Commonwealth of Massachusetts. Department of Public Health. Early Intervention Operational Standards. 2013 Jul. Accessed at: https://www.mass.gov/files/documents/2016/07/nw/ei-operational- standards.pdf

Commonwealth of Massachusetts. MassHealth Provider Bulletins. Accessed at: https://www.mass.gov/masshealth-provider-bulletins

Commonwealth of Massachusetts. MassHealth Provider Manuals. Accessed at: https://www.mass.gov/lists/masshealth-provider-manuals

Commonwealth of Massachusetts. MassHealth Transmittal Letters. Accessed at: https://www.mass.gov/masshealth-transmittal-letters

Delphi M, Zamiri Abdollahi F. Dichotic training in children with auditory processing disorder. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:114-117. doi: 10.1016/j.ijporl.2018.05.014. Epub 2018 May 26. PMID: 29859570.

de Wit E, van Dijk P, Hanekamp S, Visser-Bochane MI, Steenbergen B, van der Schans CP, Luinge MR. Same or Different: The Overlap Between Children With Auditory Processing Disorders and Children With Other Developmental Disorders: A Systematic Review. Ear Hear. 2018 Jan/Feb;39(1):1-19. doi: 10.1097/AUD.0000000000000479. PMID: 28863035.

de Wit E, Visser-Bochane MI, Steenbergen B, van Dijk P, van der Schans CP, Luinge MR. Characteristics of Auditory Processing Disorders: A Systematic Review. J Speech Lang Hear Res. 2016 Apr 1;59(2):384- 413. doi: 10.1044/2015_JSLHR-H-15-0118. PMID: 27082630.

Flanagan S, Zorilă TC, Stylianou Y, Moore BCJ. Speech Processing to Improve the Perception of Speech in Background Noise for Children with Auditory Processing Disorder and Typically Developing Peers. Trends Hear. 2018 Jan-Dec;22:2331216518756533. doi: 10.1177/2331216518756533. PMID: 29441834. Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Gates GA, Anderson ML, Feeney MP, McCurry SM, Larson EB. Central auditory dysfunction in older persons with memory impairment or Alzheimer dementia. Arch Otolaryngol Head Neck Surg. 2008 Jul;134(7):771-7. doi: 10.1001/archotol.134.7.771. PMID: 18645130.

Gyldenkærne P, Dillon H, Sharma M, Purdy SC. Attend to this: the relationship between auditory processing disorders and attention deficits. J Am Acad Audiol. 2014 Jul-Aug;25(7):676-87;quiz 706-7. doi: 10.3766/jaaa.25.7.6. PMID: 25365370.

Heimrath K, Fiene M, Rufener KS, Zaehle T. Modulating human auditory processing by transcranial electrical stimulation. Front Cell Neurosci. 2016 Mar 7;10:53. doi: 10.3389/fncel.2016.00053. eCollection 2016. PMID: 27013969.

Heine C, Slone M. Case studies of adults with central auditory processing disorder: Shifting the spotlight! SAGE Open Med Case Rep. 2019;7:2050313X18823461. doi:10.1177/2050313X18823461.

Koravand A, Jutras B, Lassonde M. Abnormalities in cortical auditory responses in children with central auditory processing disorder. Neuroscience. 2017 Mar 27;346:135-148. doi: 10.1016/ j.neuroscience.2017.01.011. Epub 2017 Jan 18. PMID: 28108252.

Iliadou V, Kiese-Himmel C. Common Misconceptions Regarding Pediatric Auditory Processing Disorder. Front Neurol. 2018 Jan 23;8:732. doi: 10.3389/fneur.2017.00732. eCollection 2017. PMID: 29410645.

Iliadou VV, Ptok M, Grech H, Pedersen ER, Brechmann A, Deggouj N, Kiese-Himmel C, Śliwińska- Kowalska M, Nickisch A, Demanez L, Veuillet E, Thai-Van H, Sirimanna T, Callimachou M, Santarelli R, Kuske S, Barajas J, Hedjever M, Konukseven O, Veraguth D, Stokkereit Mattsson T, Martins JH, Bamiou DE. A European Perspective on Auditory Processing Disorder-Current Knowledge and Future Research Focus. Front Neurol. 2017 Nov 21;8:622. doi: 10.3389/fneur.2017.00622. eCollection 2017. PMID: 29209272.

Ludwig AA, Fuchs M, Kruse E, Uhlig B, Kotz SA, Rübsamen R. Auditory processing disorders with and without central auditory discrimination deficits. J Assoc Res Otolaryngol. 2014 Jun;15(3):441-64. PMID: 24658855.

Milner R, Lewandowska M, Ganc M, Włodarczyk E, Grudzień D, Skarżyński H. Abnormal Resting-State Quantitative Electroencephalogram in Children With Central Auditory Processing Disorder: A Pilot Study. Front Neurosci. 2018 May 11;12:292. doi: 10.3389/fnins.2018.00292. eCollection 2018. PMID: 29867312.

Moore DR. The diagnosis and management of auditory processing disorder. Lang Speech Hear Serv Sch. 2011 Jul;42(3):303-8. doi: 10.1044/0161-1461(2011/10-0032). PMID: 21757566.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Moore DR, Sieswerda SL, Grainger MM, Bowling A, Smith N, Perdew A, Eichert S, Alston S, Hilbert LW, Summers L, Lin L, Hunter LL. Referral and Diagnosis of Developmental Auditory Processing Disorder in a Large, United States Hospital-Based Audiology Service. J Am Acad Audiol. 2018 May;29(5):364-77. doi: 10.3766/jaaa.16130. PMID: 29708487.

National Institute on Deafness and Other Communication Disorders (NIDCD). Auditory Processing Disorder. 2010 Jun 7. Accessed at: https://www.nidcd.nih.gov/health/auditory-processing-disorder

National Institute on Deafness and Other Communication Disorders (NIDCD). Study Shows Variety of Approaches Help Children Overcome Auditory Processing and Language Problems. 2008 Jan 30. Accessed at: https://www.nidcd.nih.gov/news/2008/study-shows-variety-approaches-help-children- overcome-auditory-processing-and-language

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New Hampshire Department of Health and Human Services. Provider Notices. Accessed at: https://www.dhhs.nh.gov/ombp/pharmacy/notices.htm

Rabelo CM, Schochat E. Sensitivity and specificity of auditory steady-state response testing. Clinics (Sao Paulo). 2011; 66(1):87-93. doi: 10.1590/S1807-59322011000100016. PMID: 21437442.

Rosen S, Cohen M, Vanniasegaram I. Auditory and cognitive abilities of children suspected of auditory processing disorder (APD). Int J Pediatr Otorhinolaryngol. 2010 Jun; 74(6):594-600. doi: 10.1016/j.ijporl.2010.02.021. Epub 2010 Mar 26. PMID: 20347161.

Policy History Original Effective Policy Original Policy Original Approval Date Date* and Version Owner Approved by Number Regulatory Approval: N/A 06/01/08 Medical Policy MPCTAC, QIC, and UMC Version 1 Manager as Internal Approval: Chair of 02/19/08: Medical Policy, Criteria, and MPCTAC Technology Assessment Committee (MPCTAC) 02/26/08: Utilization Management Committee (UMC) 03/12/08: Quality Improvement Committee (QIC) *Effective Date for the Well Sense Health Plan Product(s): 08/01/15 *Effective Date for Qualified Health Plans/ConnectorCare/Employer Choice Direct Product(s): 08/01/15

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Policy Revisions History Revision Review Effective Date Summary of Revisions Approved by Date and Version Number 01/27/09 No changes. Version 2 01/27/09: MPCTAC 01/27/09: UMC 02/25/09: QIC 01/26/10 Updated references. Version 3 01/26/10: MPCTAC 02/24/10: QIC 01/01/11 Updated references. Version 4 01/19/11: MPCTAC 02/23/11: QIC 01/01/12 Annual review, no changes, updated Version 5 01/18/12: MPCTAC references. 02/08/12: QIC 06/01/12 Updated references and revised the Version 6 06/20/12: MPCTAC introductory paragraph in Applicable Coding 07/25/12: QIC section. 06/01/13 Review with effective date 08/01/13. Moved 08/01/13 06/19/13: MPCTAC definition of central auditory processing Version 7 07/18/13: QIC disorder (CAPD) from the Description of Item or Service section to the Definitions section. Added new Description of Item or Service to describe the evaluation of central auditory processing to diagnosis CAPD. Updated Summary and References sections. Revised title and definition. Reformatted criteria in Medical Policy Statement and Limitations sections without changing criteria. Removed duplicate text from Clinical Background Information section and referenced applicable Plan policies. 05/01/14 Review for effective date of 07/01/14. Clarified 07/01/14 05/21/14: MPCTAC Medical Policy Statement section without Version 8 06/11/14: QIC changing criteria. Updated Clinical Background Information and References sections. 04/01/15 Review for effective date 08/01/15. Updated 08/01/15 04/15/15: MPCTAC Summary, Description of Item or Service, Version 9 05/13/15: QIC Definitions, Clinical Background Information, and References sections. Revised criteria in the Medical Policy Statement and Limitations sections, expanding testing beyond age 21 for MassHealth members and removing the prior authorization requirement when frequency guidelines are not exceeded and medical criteria are met and documented in the Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Policy Revisions History member’s medical record. Added Well Sense Health Plan products and Qualified Health Plans/ConnectorCare/ Employer Choice Direct as applicable products for the updated criteria and policy guidelines. Removed Commonwealth Care, Commonwealth Choice, and Employer Choice from the list of applicable products because the products are no longer available. Included separate Definitions sections for BMC HealthNet Plan products and Well Sense Health Plan products. 06/01/15 Review for effective date 08/01/15 and 08/01/15 06/17/15: MPCTAC replacing version 10. Clarified text in the Version 10 07/08/15: QIC Medical Policy Statement section without changing criteria. 11/25/15 Review for effective date 01/01/16. Updated 01/01/16 11/18/15: MPCTAC template with list of applicable products. Version 11 11/25/15: MPCTAC Revised language in the Applicable Coding (electronic vote) section. 12/09/15: QIC 05/01/16 Review for effective date 07/01/16. Updated 07/01/16 05/18/16: MPCTAC references. Version 12 06/08/16: QIC 05/01/17 Review for effective date 06/01/17. Updated 06/01/17 05/17/17: MPCTAC References and Reference to Applicable Laws Version 13 and Regulations sections. 06/01/18 Review for effective date 07/01/18. Updated 07/01/18 06/20/18: MPCTAC Description of Item or Service, References, and Version 14 Other Applicable Policies sections. 05/01/19 Review for effective date 08/01/19. 08/01/19 05/15/19: MPCTAC Administrative changes made to the Version 15 Limitations, Definitions, References, Other Applicable Policies, and Reference to Applicable Laws and Regulations sections. Criteria revised in the Medical Policy Statement section. 12/01/19 Review for effective date 01/01/20. 01/01/20 12/18/19: MPCTAC Administrative changes made to the Definitions Version 16 for BMC HealthNet Plan Products, Definitions for Well Sense Health Plan Products, References, and Reference to Applicable Laws and Regulations sections. 12/01/20 Review for effective date 01/01/21. Updated 01/01/21 12/16/20: MPCTAC the References section. Version 17

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Last Review Date 12/01/20

Next Review Date 12/01/21

Authorizing Entity MPCTAC

Other Applicable Policies Medical Policy - Autism Spectrum Disorders Medical Diagnosis and Treatment, policy number OCA 3.724 Medical Policy - Functional Therapy for a Member Age 20 or Younger in the Outpatient Setting, Including Occupational Therapy, Physical Therapy, and/or Speech Therapy, policy number OCA 3.531 (Well Sense Health Plan products) Medical Policy - Medically Necessary, policy number OCA 3.14 Medical Policy - Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 21 Years of Age or Older in the Outpatient Setting, policy number OCA 3.542 (Well Sense Health Plan products) Medical Policy - Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 20 Years of Age or Younger in the Outpatient Setting, policy number OCA 3.55 (BMC HealthNet Plan products) Medical Policy - Speech Therapy, Language Therapy, Voice Therapy, or Auditory Rehabilitation for a Member 21 Years of Age or Older in the Outpatient Setting, policy number OCA 3.551 (BMC HealthNet Plan products) Reimbursement Policy - Early Intervention, policy number 4.3 Reimbursement Policy - Early and Periodic Screening, Diagnosis and Treatment, policy number WS 4.15 Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Billing and Coding Guidelines, policy number WS 4.31 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number WS 4.18 Reimbursement Policy - Non-Reimbursed Codes, policy number 4.38 Reimbursement Policy - Non-Reimbursed Codes, policy number WS 4.38 Reimbursement Policy - Outpatient Hospital, policy number 4.17 Reimbursement Policy - Outpatient Hospital, policy number SCO 4.17 Reimbursement Policy - Physical, Occupational, and Speech Rehabilitation Modalities and Therapeutic Procedures, policy number 4.609

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Reimbursement Policy - Physical, Occupational and Speech Rehabilitation Modalities and Therapeutic Procedures, policy number WS 4.27 Reimbursement Policy - Physician and Non-Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Physician and Non Physician Practitioners, policy number WS 4.28 Reimbursement Policy - Provider Preventable Conditions and Serious Reportable Events, policy number 4.610 Reimbursement Policy - Provider Preventable Conditions and Serious Reportable Events, policy number WS 4.29

Reference to Applicable Laws and Regulations 42 CFR 440.40. Code of Federal Regulations. Nursing facility services for individuals age 21 or older (other than services in an institution for mental disease), EPSDT, and family planning services and supplies.

114.3 CMR 17.00. Code of Massachusetts Regulations. Division of Health Care Finance and Policy. Medicine.

114.3 CMR 39.00. Code of Massachusetts Regulations. Rehabilitation Center Services, Audiological Services, Restorative Services.

130 CMR 426.000. Code of Massachusetts Regulations. Division of Medical Assistance. Audiology Manual.

130 CMR 440.00. Division of Medical Assistance. Code of Massachusetts Regulations. Early Intervention Program Services.

Chapter He-W 530. New Hampshire Medical Assistance. Service Limits, Co-Payments, and Non-Covered Services. Definition of Medically Necessary.

Chapter He-W 531. New Hampshire Code of Administrative Rules. Medical Assistance. Physician Services.

Chapter He-W 546. New Hampshire Medical Assistance. Early and Periodic Screening, Diagnosis and Treatment Service.

Chapter He-W 567. New Hampshire Medical Assistance. Hearing Aid Services.

Chapter He-W 568. New Hampshire Medical Assistance. Physical Therapy, Occupational Therapy and Services for Individuals with Speech, Hearing and Language Disorders.

The Hearing Aid Law for Children. Commonwealth of Massachusetts. Chapter 233 of the Acts of 2012.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder

Individuals with Disabilities Education Act (IDEA) of 2004.

MGL ch.175 § 47X. Massachusetts General Laws. Insurance. Diagnosis and Treatment of Speech, Hearing, and Language Disorders.

MGL ch.71B. Massachusetts General Laws. The Children with Special Needs Law.

MGL ch.111G. Massachusetts General Laws. Early Childhood Intervention Services.

MGL ch.175 § 47X. Massachusetts General Laws. Insurance. Diagnosis and Treatment of Speech, Hearing, and Language Disorders.

MGL ch.176B § 4EE. Massachusetts General Laws. Massachusetts Hearing Aid Law for Children 21 Years of Age or Younger for Hearing Aids and Related Services (2012).

RSA 186-C: 29. New Hampshire Revised Statutes Annotated. Medicaid Funded Services. Individualized Education Plan.

RSA 420-E. New Hampshire Revised Statutes Annotated. Insurance. Licensure of Medical Utilization Review Entitles.

+ Disclaimer Information: Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Central Auditory Function Evaluation to Diagnose Central Auditory Processing Disorder