Aural Rehabilitation

Number: 0034

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses aural rehabilitation.

1. Medical Necessity

   Aetna considers aural rehabilitation (including auditory verbal therapy [AVT]) 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

   • CPB 0013 - Cochlear Implants and Auditory Brainstem Implants

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
Auditory verbal therapy -no specific code
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

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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.

Auditory Verbal Therapy

Auditory verbal therapy (AVT) is a specialized type of therapy designed to teach a child to use the hearing provided by a hearing aid or a cochlear implant for understanding speech and learning to talk.  The child is taught to develop hearing as an active sense so that listening becomes automatic and the child seeks out sounds in life – hearing and active listening become an integral part of communication, recreation, socialization, education, and work (Listening for Life, 2014).  According to the Alexander Graham Bell (AG Bell) Academy for Listening and Spoken Language, AVT promotes early diagnosis, 1-on-1 therapy, and state-of-the-art audiologic management and technology. Parents and care-givers actively participate in therapy. Through guidance, coaching, and demonstration, parents become the primary facilitators of their child’s spoken language development (Houston, 2012). 

Goldberg and Flexer (2001) updated an earlier study on American and Canadian graduates of auditory-verbal programs.  Survey research was conducted to obtain information on a variety of topics.  Overall, the current results again indicated that the majority of respondents were integrated into "regular" or "typical" learning and living environments.  In view of the earlier identification of hearing loss and the early fitting of sensory aids and availability of cochlear implant technology, coupled with intervention that emphasizes auditory learning, it was suggested that today's infants have the potential to become independent, participating, and contributing citizens in mainstream society.

Hogan et al (2008) noted that providing unbiased data concerning the outcomes of particular intervention methods is imperative if professionals and parents are to assimilate information which could contribute to an "informed choice".  An evaluation of AVT was conducted using a formal assessment of spoken language as an outcome measure.  Spoken language scores were obtained on entry to the study and re-administered at intervals of at least 6 months.  Predicted language scores in the absence of auditory verbal (AV) intervention were calculated according to a model.  Predicted and actual rates of language development (RLD) were compared.  The heterogeneity of this group of children derived from their degree of hearing loss, the etiology of each child's loss, the type of hearing technology used and the age at which they started therapy.  For all age groups and for each of the different hearing technologies, AVT was found to be a highly effective program for accelerating spoken language development when using RLD as an outcome measure.  The major drawbacks of this study were the lack of control groups or randomized controls, so it is not possible to conclude whether AVT was the cause of the progress seen in these children

In a Cochrane review, Brennan-Jones (2014) evaluated the effectiveness of AVT in developing receptive and expressive spoken language in children who are hearing impaired.  CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, speechBITE and eight other databases were searched in March 2013.  These investigators also searched 2 trials registers and 3 theses repositories, checked reference lists and contacted study authors to identify additional studies.  The review considered prospective RCTs and quasi-randomized studies of children (birth to 18 years) with a significant (greater than or equal to 40 dBHL) permanent (congenital or early-acquired) hearing impairment, undergoing a program of AVT, administered by a certified auditory-verbal therapist for a period of at least 6 months.  Comparison groups considered for inclusion were waiting list and treatment as usual controls.  Two review authors independently assessed titles and abstracts identified from the searches and obtained full-text versions of all potentially relevant articles.  Articles were independently assessed by 2 review authors for design and risk of bias.  In addition to outcome data, a range of variables related to participant groups and outcomes were documented.  Of 2,233 titles and abstracts searched, only 13 abstracts appeared to meet inclusion criteria.  All 13 full-text articles were excluded following independent evaluation by 2 review authors (CGBJ and JW), as they did not meet the inclusion criteria related to the research design.  Thus, no studies are included in this review.  The authors concluded that this review confirmed the lack of well-controlled studies addressing the use of AVT as an intervention for promoting spoken language development in children with permanent hearing impairments.  They stated that while lack of evidence does not necessarily imply lack of effect, it is at present not possible for conclusions to be drawn as to the effectiveness of this intervention in treating children with permanent hearing impairments.

An UpToDate review on "Hearing loss in children: Treatment" (Smith and Gooi, 2022) state that important prerequisites for preoperative evaluation "include access to an education program that stresses auditory and verbal skills and highly motivated parents who have realistic expectations".

Noel et al (2023) conducted a systematic review on the efficacy of AVT in children with cochlear implants (CI) based on their auditory performance. Their review, which focused on findings from 2010 through 2021, was designed per the Popular Reporting Systems for the Systematic Review and Analysis of Meta-Analysts (PRISMA), the 2020 revised version, and the Critical Evidence for Clinical Evidence (CATE) checklist. Their results discovered "an important progression based on the auditory performance among children with cochlear implantation who received habilitation". The studies highlighted that "younger the age at implantation better the auditory performance", which "may be necessary to allow at least relatively normal organization of auditory pathways in pre-lingual children with hearing impairment. Therefore, regular revitalization of aural-verbal rehabilitation and speech and language therapy is essential for younger children with hearing impairment to achieve the highest level of hearing function". The authors concluded that their "review highlights importance of assessment of the auditory performance to be considered in the test battery while evaluating children with CI before and after habilitation along with AVT".

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.

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References