This is the third in a series of Weekly Alerts describing significant gaps in Medicare coverage;  see Alerts regarding dental services (June 7, 2007) and eyeglasses (September 20, 2007).  This week's Alert discusses limitations on Medicare coverage for hearing aids.

The exclusion of some hearing aids is specified in the Medicare statute, which states that payment is prohibited:

where such expenses are for routine physical checkups, eyeglasses . . . or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed . . . to determine the refractive state of the eyes, hearing aids or examinations therefore, . . . .[1]

The legislative history indicates that Congress intended the exclusions of coverage of the various services listed in this section of the Medicare statute to apply only to "routine" services.  It states:

Payments would not be made for routine physical examinations or for eyeglasses, hearing aids, or the fitting expenses or other costs incurred in connection with their purchase.  The committee bill provides a specific exclusion of routine dental care to make clear that the services of dental surgeons covered under the bill are restricted to complex surgical procedures.  Thus…a routine annual or semiannual [physician’s] checkup would not be covered...Similarly, too, routine dental treatment - filling, removal, or replacement of teeth or treatment of structures directly supporting teeth - would not be covered. Neither would payment be made for orthopedic shoes or other supportive devices for the feet.[2] 

Despite this indication that the coverage exclusion applies only to hearing aids needed in routine situations, the Medicare regulations do not limit the exclusion of hearing aids.  Coverage is excluded broadly, for: 

(d) Hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids.[3]

The Medicare policy manual, which controls initial decisions on coverage that are made by the Medicare claims processing contractors, excludes coverage of all hearing aids.   It states:

Hearing aids are amplifying devices that compensate for impaired hearing.  Hearing aids include air conduction devices that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound.  They also include bone conduction devices that provide mechanical energy to the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.[4]

Although hearing aids are not covered, the policy manual does allow Medicare coverage of prosthetic devices to aid hearing in certain circumstances.  Prosthetic devices are defined as "devices that produce perception of sound by replacing the function of the middle ear, cochlea or auditory nerve."[5]  The following are considered by Medicare to be prosthetic devices:

• Cochlear implants and auditory brainstem implants, i.e., devices that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays. 

• Osseointegrated implants, i.e., devices implanted in the skull that replace the function of the middle ear and provide mechanical energy to the cochlea via a mechanical transducer.[6]

Medicare’s restrictive policy against coverage of hearing aids creates presents a major obstacle for many beneficiaries who need hearing aids.  This is a particular hardship for low and moderate income beneficiaries.  Costs for hearing aids in the United States range from $500 to $5,000.[7]  In contrast, other industrialized countries including Australia, Canada, Iceland, and the United Kingdom provide free or discounted hearings aids to beneficiaries of their public health care systems.[8]