1. (a) A provider must obtain prior authorization from the department before the department will pay for

   1. (1) the purchase of a replacement cochlear implant part or rechargeable lithium ion battery;
   2. (2) the rental of hearing aids;
   3. (3) the purchase of a hearing item that exceeds a limit under 7 AAC 115.530;
   4. (4) a payment request that exceeds the maximum allowable payment for a hearing item;
   5. (5) a customized hearing aid;
   6. (6) a monaural hearing aid or binaural hearing aid for which a payment rate has not been established;

   7. (7) the purchase of the following hearing services or hearing items identified as miscellaneous in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900:

      1. (A) a personal FM system, for a recipient under 21 years of age with hearing loss diagnosed by an audiologist licensed under AS 08.11;
      2. (B) a hearing aid;
      3. (C) a hearing aid accessory;
      4. (D) a hearing aid supply;
      5. (E) a hearing service.

2. (b) To request prior authorization, a hearing services provider must

   1. (1) complete a certificate of medical necessity form provided by the department;

   2. (2) include documentation that a licensed health care practitioner working within the scope of that practitioner's license has

      1. (A) determined that the service is medically necessary;
      2. (B) conducted a clinical assessment of the recipient; and
      3. (C) prepared a treatment plan.
3. (c) In addition to the requirements of (b) of this section, a hearing services provider requesting prior authorization for a payment amount that exceeds the maximum allowable payment must include a written statement that the recipient's condition requires the more costly item or service.

4. (d) In addition to the requirements of (b) of this section, a hearing services provider requesting prior authorization for replacement of a hearing item under 7 AAC 115.530(j) must show evidence satisfactory to the department that the item

   1. (1) is necessary to replace a hearing item that is under repair;
   2. (2) is necessary to replace a hearing item that has been in continuous use by the recipient for the item's reasonable useful lifetime; or
   3. (3) is not covered by a manufacturer's warranty and is determined to be damaged as the result of a manufacturing defect or owner's negligence.

5. (e) The department will review a request for prior authorization on an individual basis. Using the data available from an auditory assessment of the recipient, the department will consider the

   1. (1) degree of the recipient's hearing loss;
   2. (2) type of recipient's hearing loss;
   3. (3) configuration of the recipient's hearing loss; and
   4. (4) management and treatment plan prepared.

6. (f) In this section, "miscellaneous" means a hearing item or hearing service listed in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, that is

   1. (1) described as "miscellaneous," "not otherwise classified," or "not otherwise specified"; or
   2. (2) without a specific description or identifier.

(Eff. 2/1/2010, Register 193)