Notification

Otoplasty or Non-Surgical External Ear Molding


Notification Issue Date: 06/12/2018

This version of the policy will become effective 09/10/2018.

This policy was updated to communicate Company's position of medically necessary non-surgical external ear molding using an ear molding device for specified criteria.

The following NOC code represents the application of ear molds used for the non-surgical correction of auricular anomalies:
69399

The following HCPCS code has been added to this policy to represent ear molds for the non-surgical correction of auricular anomalies:
A9999 Miscellaneous DME supply or accessory, not otherwise specified

The following ICD-10 CM codes have been added to this policy:

M95.10 Cauliflower ear, unspecified ear

Q17.3 Other misshapen ear

Q17.4 Misplaced ear

Q17.5 Prominent ear

Q17.8 Other specified congenital malformations of ear

S08.111A Complete traumatic amputation of right ear, initial encounter

S08.111D Complete traumatic amputation of right ear, subsequent encounter

S08.111S Complete traumatic amputation of right ear, sequela

S08.112A Complete traumatic amputation of left ear, initial encounter

S08.112D Complete traumatic amputation of left ear, subsequent encounter

S08.112S Complete traumatic amputation of left ear, sequela

S08.119A Complete traumatic amputation of unspecified ear, initial encounter

S08.119D Complete traumatic amputation of unspecified ear, subsequent encounter

S08.119S Complete traumatic amputation of unspecified ear, sequela

S08.121A Partial traumatic amputation of right ear, initial encounter

S08.121D Partial traumatic amputation of right ear, subsequent encounter

S08.121S Partial traumatic amputation of right ear, sequela

S08.122A Partial traumatic amputation of left ear, initial encounter

S08.122D Partial traumatic amputation of left ear, subsequent encounter

S08.122S Partial traumatic amputation of left ear, sequela

S08.129A Partial traumatic amputation of unspecified ear, initial encounter

S08.129D Partial traumatic amputation of unspecified ear, subsequent encounter

S08.129S Partial traumatic amputation of unspecified ear, sequela



Medical Policy Bulletin


Title:Otoplasty or Non-Surgical External Ear Molding

Policy #:11.01.01j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

MEDICALLY NECESSARY

OTOPLASTY
Otoplasty is considered medically necessary and, therefore, covered when any of the following criteria are met:
  • The individual has deformities and/or defects of the ear caused by trauma and/or accident.
  • The individual has deformities and/or defects of the ear caused by disease or tumors/cancer that result in a significant functional hearing impairment.
  • The individual has congenital or acquired physiologic deformities of the ear that result in a significant functional hearing impairment (e.g., microtia, cryptotia).

In exceptional circumstances where there is marked deformity resulting from severe local trauma, sequelae of radiation therapy, tumor, or severe congenital or acquired craniofacial anomaly, otoplasty that is performed in the absence of additional comprehensive craniofacial reconstructive procedures may be considered medically necessary and, therefore, covered. Photographs demonstrating the deformity may be required to determine coverage.

Otoplasty performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.

NON-SURGICAL EXTERNAL EAR MOLDING
Non-surgical external ear molding using an ear molding device (e.g., EarWell Correction System, EarBuddies splints) is considered medically necessary and, therefore, covered when there is a congenital malformation of the ear causing a significant functional hearing impairment as evidenced by diagnostic testing (e.g., diagnostic auditory brain stem response [ABR]).

COSMETIC

OTOPLASTY OR NON-SURGICAL EXTERNAL EAR MOLDING
Otoplasty or non-surgical external ear molding using an ear molding device (e.g., EarWell Correction System™, EarBuddies™ splints) performed solely to change the appearance of any portion of the ear, without the expectation of improving physiologic functioning, is considered a cosmetic service.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for otoplasty require review by the Company and must include color photographs and a letter of medical necessity from the provider.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, otoplasty is covered under the medical benefits of the Company's products when medical necessity criteria in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

OTOPLASTY

Otoplasty is a surgical procedure that involves reshaping the outer portion of the ear (i.e., auricle), thereby correcting defects resulting from trauma and/or accident, tumors, or congenital deformities of the ear that have caused a functional hearing impairment. Otoplasty can be performed for either reconstructive or cosmetic purposes.

RECONSTRUCTIVE SURGERY
Reconstructive surgery is the use of surgery to restore the form and function to parts of the body that have been subject to trauma and/or accident, congenital deformities, or tumors/cancer. Deformities or defects resulting from trauma and/or accident, infection, or tumors may require reconstructive surgery in order to improve physiologic function or to approximate a more normal appearance of the ear. Additionally, surgical excision of skin neoplasms can cause permanent changes in the structure of the ear that may require otoplasty.

Microtia and cryptotia are examples of congenital ear deformities and are often associated with other abnormalities that may cause a functional impairment and affect sound conduction within the ear. In microtia, a small and malformed auricle is usually characteristic of stenosis, atresia (i.e., closure) of the external auditory canal, or other developmental abnormalities of the middle ear that may cause a conductive hearing loss. Microtia may result in subtle abnormalities or a more severe deformity. The surgical repair of microtia is sometimes completed in several stages. Cryptotia is also known as buried ear or hidden ear. Cryptotia refers to an ear that appears to have its upper portion buried underneath the side of the head. The condition also involves under-developed scapha (i.e., the curved depression separating the helix and antihelix of the ear) and antihelical crura or the external portion of the ear. Cryptotia occurs when the upper pole of the ear cartilage is buried beneath the skin of the scalp and requires a surgical release and/or reconstruction.

Prominent ears, sometimes referred to as "lop-ear" or "cup ears," are a deformity where the ears project more than the normal distance from the skull. One of the most common congenital ear deformities is a lop ear (i.e., protruding ear), which results from a failure of the antihelical fold to develop properly, creating an excessive protrusion of the conchal cartilage. This malformation, depending on the severity of the deformity, may be corrected by surgical creation of an antihelical fold, by reduction of the conchal cartilage projection, or by a combination of the two.

Traditionally, otoplasty to correct congenital anomalies has been done in children ages five to seven years because, by this time, the ear has attained 85 to 90 percent of its adult size, and the surgeon can thus conduct surgery based on a more accurate estimation of the final size and shape of the ear.

NON-SURGICAL EXTERNAL EAR MOLDING

Although surgical procedures have traditionally been used to reconstruct congenital auricular malformation and deformities, ear molding proposes to treat deformational auricular anomalies nonsurgically using an ear molding device. Congenital auricular deformities can be associated with other congenital syndromes, although they are most often found in isolation. The prefabricated ear mold systems may be used by plastic surgeons with the goal to improve or correct many infant ear anomalies present at birth including protruding ears, helical rim anomalies, Stahl’s ear, lop ear, and cryptotia. However, molding is not possible for more severe deformities that involve major deficiencies of cartilage and skin such as microtia and severe cases of constricted ears.Several commercial ear molding systems are available for the application of ear molding. The ear molds are left in place 24 hours a day. The duration of molding varies according to the age of the child and the response to molding.

Non-surgical external ear molding can reshape the ear during the narrow window when circulating maternal estrogen remains at a high level in the child, such that infants should be referred for molding within the first 2-3 weeks of life. It is proposed that the high level of estrogen at birth correlates with increased hyaluronic acid, which inhibits the linking of the cartilage intercellular matrix. If the cartilage is molded while maternal estrogen circulates within the newborn, it tends to retain its new shape as the maternal estrogen is metabolized.

COSMETIC SURGERY

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement does not constitute improvement in physiologic function.
References


American Academy of Otolaryngology-Head and Neck Surgery. Ear plastic surgery. [Entnet Web site]. 2018. Available at: http://www.entnet.org/content/ear-plastic-surgery. Accessed February 22, 2018.

American Academy of Otolaryngology-Head and Neck Surgery. Conductive hearing loss: causes and treatments. [Entnet Web site]. 2018. Available at:
http://www.entnet.org/content/conductive-hearing-loss-causes-and-treatments. Accessed February 22, 2018.

American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Ear deformity: prominent ears. [ASPS Web site]. December 2005. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Otoplasty2.pdf. Accessed February 22, 2018.

Amin K, Hone R, Kanegaonkar R. Audiologic changes after pinna augmentation. Ear Nose Throat J. 2016;95(8):E14-7.

Baker SB, Kumar AR. American Academy of Pediatrics. Nonsurgical ear molding improves many anomalies with few complications. [AAP Web site]. 12/06/2016. Available at: http://www.aappublications.org/news/2016/12/06/Ear120616. Accessed February 22, 2018.

Bartel-Friedrich S, Wulke C. Classification and diagnosis of ear malformations. GMS Current Topics in Otorhinolaryngology, Head and Neck Surgery. 2007;6:Doc05.

Brown FE, Colen LB, Addante RR, et al. Correction of congenital auricular deformities by splinting in the neonatal period. Pediatrics. 1986;78(3):406-411.

Byrd HS, Langevin CJ, Ghidoni LA. Ear molding in newborn infants with auricular deformities.
Plast Reconstr Surg. 2010;126(4):1191-200.

Burres S. The anterior-posterior otoplasty. Arch Otolaryngol Head Neck Surg. 1998;124(2) :181-185.

Company Benefit Contracts.

Daniali LN, Rezzadeh K, Shell C, et al. Classification of newborn ear malformations and their treatment with the EarWell Infant Ear Correction System. Plast Reconstr Surg. 2017;139(3):681-691.

Ducic Y, Hilger PA. Effective step-by-step technique for the surgical treatment of protruding ears. J Otolaryngol. 1999;28(2):59-64.

Gosain AK, Kumar A, Huang G. Prominent ears in children younger than 4 years of age: what is appropriate timing for otoplasty? Plast Recontr Surg. 2004;114(5):1042-54.

Hell B, Garbea D, Heissler E, et al. Otoplasty: a combined approach to different structures of the auricle. Int J Oral Maxillofac Surg. 1997;26(6):408-413.

Manstein CH. Congenital ear deformities. [eMedicine Web site]. 08/17/2017. Available at: http://www.emedicine.com/plastic/topic207.htm. Accessed February 22, 2018.

March of Dimes. Hearing Loss. [March of Dimes Web stie]. June 2014. Availabe at:
https://www.marchofdimes.org/complications/hearing-impairment.aspx. Accessed February 22, 2018.

McNeil ML, Aiken SJ, Bance M, et al. Can otoplasty impact hearing? A prospective randomized controlled study examining the effects of pinna position on speech reception and intelligibility. J Otolaryngol Head Neck Surg. 2013;42(1):10

Marks MW, Marks C. Fundamentals of Plastic Surgery. 1st ed. Philadelphia, PA: WB Saunders Co; 1997.

Messner AH, Crysdale WS. Otoplasty. Clinical protocol and long-term results. Arch Otolaryngol Head Neck Surg. 1996;122(7):773-777.

Mohammadi AA, Imani MT, Kardeh S, et al. Non-surgical Management of Congenital Auricular Deformities. World J Plastic Surg. 2016;5(2):139-147.

Rowe LD. Otolaryngology: head and neck surgery. In: Way LW, ed. Current Surgical Diagnosis and Treatment. 10th ed. Norwalk, CT: Appleton & Lange; 1994: 870.

Smith W, Toye J, Reid A, et al. Nonsurgical correction of congenital ear abnormalities in the newborn: Case series. Paediatr Child Health. 2005;10(6):327-331.

Snow JB. Surgical disorders of the ears, nose, paranasal sinuses, pharynx, and larynx. In: Sabiston DC Jr., Lyerly HK, eds. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia, PA: WB Saunders Co; 1997: 1281.

Songu M, Adibelli H. Otoplasty in children younger than 5 years of age. Int J Pediatr Otorhinolaryngol.2010;74(3):292-6.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

13151, 13152, 13153, 14060, 14061, 15260, 15261, 21230, 21235, 69300, 69310, 69320

THE FOLLOWING CODE IS USED TO REPRESENT FABRICATION OF EAR CARTILAGE
69399

THE FOLLOWING CODE IS USED TO REPRESENT THE APPLICATION OF EAR MOLDS (EAR MOLDING)
69399


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

H61.311 Acquired stenosis of right external ear canal secondary to trauma

H61.312 Acquired stenosis of left external ear canal secondary to trauma

H61.313 Acquired stenosis of external ear canal secondary to trauma, bilateral

M95.10 Cauliflower ear, unspecified ear

M95.11 Cauliflower ear, right ear

M95.12 Cauliflower ear, left ear

Q16.0 Congenital absence of (ear) auricle

Q16.1 Congenital absence, atresia and stricture of auditory canal (external)

Q16.9 Congenital malformation of ear causing impairment of hearing, unspecified

Q17.2 Microtia

Q17.3 Other misshapen ear

Q17.4 Misplaced ear

Q17.5 Prominent ear

Q17.8 Other specified congenital malformations of ear

S08.111A Complete traumatic amputation of right ear, initial encounter

S08.111D Complete traumatic amputation of right ear, subsequent encounter

S08.111S Complete traumatic amputation of right ear, sequela

S08.112A Complete traumatic amputation of left ear, initial encounter

S08.112D Complete traumatic amputation of left ear, subsequent encounter

S08.112S Complete traumatic amputation of left ear, sequela

S08.119A Complete traumatic amputation of unspecified ear, initial encounter

S08.119D Complete traumatic amputation of unspecified ear, subsequent encounter

S08.119S Complete traumatic amputation of unspecified ear, sequela

S08.121A Partial traumatic amputation of right ear, initial encounter

S08.121D Partial traumatic amputation of right ear, subsequent encounter

S08.121S Partial traumatic amputation of right ear, sequela

S08.122A Partial traumatic amputation of left ear, initial encounter

S08.122D Partial traumatic amputation of left ear, subsequent encounter

S08.122S Partial traumatic amputation of left ear, sequela

S08.129A Partial traumatic amputation of unspecified ear, initial encounter

S08.129D Partial traumatic amputation of unspecified ear, subsequent encounter

S08.129S Partial traumatic amputation of unspecified ear, sequela




HCPCS Level II Code Number(s)


THE FOLLOWING CODE IS USED TO REPRESENT EAR MOLDS

A9999 Miscellaneous DME supply or accessory, not otherwise specified



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

11.01.01j:
09/10/2018This version of the policy will become effective 09/10/2018.

This policy was updated to communicate Company's position of medically necessary non-surgical external ear molding using an ear molding device for specified criteria.

The following NOC code represents the application of ear molds used for the non-surgical correction of auricular anomalies:
69399

The following HCPCS code has been added to this policy to represent ear molds for the non-surgical correction of auricular anomalies:
A9999 Miscellaneous DME supply or accessory, not otherwise specified

The following ICD-10 CM codes have been added to this policy:

M95.10 Cauliflower ear, unspecified ear
Q17.3 Other misshapen ear
Q17.4 Misplaced ear
Q17.5 Prominent ear
Q17.8 Other specified congenital malformations of ear
S08.111A Complete traumatic amputation of right ear, initial encounter
S08.111D Complete traumatic amputation of right ear, subsequent encounter
S08.111S Complete traumatic amputation of right ear, sequela
S08.112A Complete traumatic amputation of left ear, initial encounter
S08.112D Complete traumatic amputation of left ear, subsequent encounter
S08.112S Complete traumatic amputation of left ear, sequela
S08.119A Complete traumatic amputation of unspecified ear, initial encounter
S08.119D Complete traumatic amputation of unspecified ear, subsequent encounter
S08.119S Complete traumatic amputation of unspecified ear, sequela
S08.121A Partial traumatic amputation of right ear, initial encounter
S08.121D Partial traumatic amputation of right ear, subsequent encounter
S08.121S Partial traumatic amputation of right ear, sequela
S08.122A Partial traumatic amputation of left ear, initial encounter
S08.122D Partial traumatic amputation of left ear, subsequent encounter
S08.122S Partial traumatic amputation of left ear, sequela
S08.129A Partial traumatic amputation of unspecified ear, initial encounter
S08.129D Partial traumatic amputation of unspecified ear, subsequent encounter
S08.129S Partial traumatic amputation of unspecified ear, sequela


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 09/10/2018
Version Issued Date: 09/10/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.