Does Medicare Require a Referral for Audiology Exams?
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Does Medicare Require a Referral for Audiology Exams?

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By Daniel Petkevich

Nov 22, 2022

Guidance has been updated recently

As you may know already, Medicare does not cover hearing aids. But you can still get Medicare coverage for tests for hearing and balance. In most cases, you will need a referral from a physician to get this covered by Medicare. The CMS (Center for Medicare & Medicaid Services) just released updated guidance for the exception for when you don't need a referral. Let's dig into it.

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When do you need an audiology exam?

You will need an audiology exam if you want to find out how well your ears are working and to determine the best treatment for any hearing issues. This may include having balance tests and learning more about assistive devices such as hearing aids, implants, or other treatments.

Audiology Exams and Medicare Coverage

Luckily, if you need an audiology exam, Medicare has you covered. This exam does require pre-authorization though. The exam must be performed by an audiologist who is an enrolled Medicare provider. If you do not have a referral from your physician, you may be able to use the Exception Request, which has recently been filed with the CMS.

What are the conditions that must be met for the exception to apply?

According to the CMS, "(t)he finalized policy will allow beneficiaries direct access (without an order from a physician or NPP) to an audiologist, but only for non-acute hearing conditions." So , if your hearing condition is not acute or emergent, and you are being seen for non-acute issues, then Medicare will need authorize the audiology exam to be eligible for coverage.

What to do if you don't have a referral?

If you don't have a referral from your physician for an audiology exam and meet the criteria for the exception, you may submit an Exception Request to Medicare. This must be done before the exam is performed, and you will need to provide all supporting documentation such as physician notes and lab results with your request. Once approved, Medicare will pay for the exam and any related services.

And as with hearing aids, Medicare might not have the same coverage as Medicare Advantage plans. You might want to check with your plan provider directly for specific coverage details.

We hope this guide helps you understand what Medicare covers regarding audiology exams. If you have any questions, please don't hesitate to reach out to us for more information. We're here to help!

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