Medical Policy

Policy Num:      02.009.003
Policy Name:    Neonatal Auditory Screening
Policy ID           [02.009.003]  [Ar / L  / M+ / P-]  [0.00.00]

Last Review:     June 23, 2023
Next Review:     Policy Archived
 

ARCHIVED

Related Policies: None

Neonatal Auditory Screening

Summary

The diagnosis of congenital hearing loss was previously made at an average age of 13 months for infants with severe to profound bilateral loss (SNHL) and at 17 months for those with mild to moderate loss. Children with hearing loss show delayed language development, learning and speech. This lag exists or becomes evident at the age of 3, but the consequences can be lifelong, leading to inadequate reading ability, poor school performance, unemployment, or poor job opportunity.

Between 50% to 75% of children with moderate to profound bilateral deafness (SNHL) have one or more specific risk factors. Until recently, programs in the E.U. They focused on identifying and screening high-risk populations. However, these programs failed to identify the high-risk population, the questionnaire was not administered, or the follow-up of already identified populations was lost. In addition, affected children who do not show risk factors are not diagnosed.

Currently, two types of tests are performed: otoacoustic emissions (OAE) and auditory brain stem response (ABR).

Most screening programs have two stages:

1. Repeat OAE twice

2. Perform an OAE and then ABR or the ABR repeated twice.

The results are sensitive to the following factors:

· Team

· Staff training

· Quality control

Single stage screening with ABR or OAE can detect between 80% to 95% of the affected cases. The protocol with OAE and ABE was more specific than the test of ABR or AOE performed alone.

In low-risk populations, there are more false positives than positives true.

About 6.7% of infants in the general population not diagnosed at the hospital they were eventually diagnosed with bilateral deafness (SNHL). In the population of low risk only 2% were not diagnosed in the hospital, but their diagnosis was carried out out eventually too.

In those children not evaluated in the hospital, it is recommended that the test be carried out between 2 to 8 weeks after the discharge date.

Positive results to these tests are subsequently validated by consultation otolaryngology and audiology, ABR, or other electrophysiology tests (as early as as the age of 3 months). Audiometry with visual reinforcement can be performed effectively at the age of 8 to 9 months.

There are no prospective controlled studies that directly demonstrate proportionally, that the neonatal screening intervention and early intervention result in increased language development, learning, etc.

In the low-risk population there are around 25% to 50% of false positives for each case of actual hearing loss. In many cases the diagnosis audiological was incorrect (7%), and eventually the infants demonstrated hearing normal when reexamined at four and 10 months.

Objective

Screening for hearing loss in the newborn will be reviewed here. 

Policy Statement

The Neonatal Hearing Screening program establishes performing hearing screening tests on all infants before leaving the Newborn Rooms of the hospital.

Policy Guidelines

Newborn hearing screening is now public policy. It is effective in terms of exhaustiveness, age at diagnosis and early management. 

When a newborn does not pass the initial hearing screen in one or both ears, a single repeat hearing screen should be completed on both ears, prior to hospital discharge. Excessive screening to obtain a pass result after a valid refer has been recorded should be avoided.

An effective neonatal hearing screening test is one that is reliable in infants ≤3 months of age and that detects hearing loss of ≥35 decibels (dB) in the better ear [27].

Two electrophysiologic techniques meet these criteria:

●Automated auditory brainstem responses (AABR)

●Otoacoustic emissions (OAE)

Both AABR and OAE techniques are inexpensive, portable, reproducible, and automated. They evaluate the peripheral auditory system and the cochlea, but cannot assess activity in the highest levels of the central auditory system. These tests alone are not sufficient to diagnose hearing loss; thus, any child who fails one of these screening tests requires further audiologic evaluation. In addition, both methods will miss mild hearing loss.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  

Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Types of hearing loss — Neonatal hearing loss can result from transient or permanent conductive, permanent sensorineural, auditory neuropathy, and mixed defects.

●Conductive loss is caused by abnormalities of the outer or middle ear, which limits the amount of external sound that gains access to the inner ear (cochlea and vestibular apparatus). Cochlear function remains normal because the inner ear develops separately from the external and middle ears. Conductive hearing loss may be either transient (middle ear fluid) or permanent (anatomical). Transient conductive hearing loss is a frequent cause of a false-positive neonatal screen [1].

●Sensorineural hearing loss (SNHL) results from malfunction of inner ear structures, including the outer and inner hair cells of the cochlea and the eighth cranial nerve components of the auditory neural pathway.

●Auditory neuropathy (AN) is a hearing disorder that affects the neural processing of auditory stimuli and may involve the eighth cranial nerve, auditory brain stem, or cerebral cortex. Sound enters the inner ear (cochlea and outer hair cells) normally, but the transmission of signals from the inner hair cells of the cochlea to the auditory nerve/pathway is either absent or severely distorted. Screening for hearing loss using otoacoustic emissions will not detect patients with AN, as their outer hair cells function normally. 

●Mixed hearing loss occurs when there is a conductive component in combination with SNHL or AN. There is impairment in the middle ear and inner ear or auditory nerve.

Severity of hearing loss — The extent of hearing loss is defined by measuring the hearing threshold in decibels (dB) at various frequencies. Normal hearing has a threshold of -10 to 15 dB.

Hearing loss ranges from slight to profound. In individuals with bilateral hearing loss, the severity of loss is based on the better-functioning ear.

Severity of hearing loss defined by the American Speech-Language Hearing Association as follows:

●No hearing loss – -10 to 15 dB

●Slight – 16 to 25 dB

●Mild – 26 to 40 dB

●Moderate – 41 to 55 dB

●Moderately severe – 56 to 70 dB

●Severe – 71 to 90 dB, or 61 to 80 dB based on the World Health Organization (WHO) definition

●Profound – >91 dB, or >80 dB based on WHO definition

Rationale

Screening newborns for hearing loss leads to earlier detection and intervention in patients with congenital hearing impairment. Early intervention can significantly improve language acquisition and educational achievement in affected patients [2,14-19].

Earlier detection — The available evidence demonstrates that screening newborns detects hearing loss at an earlier age than relying solely on identifying clinical signs of hearing loss [20-25]. This is because caregivers and clinicians are often not able to detect hearing loss in infants until there are signs of delayed speech and language development.

This point was best illustrated by a clinical trial carried out in the 1990s at four hospitals in England [20,25]. Over a three-year period, the hospitals alternated between six-month periods of screening all newborns and periods of no screening. Among the 25,609 infants born during screening periods, 27 were found to have bilateral permanent hearing loss (incidence 105 per 100,000 live born infants) and among the 28,172 infants born during periods without screening, 26 were found to have bilateral permanent hearing loss (incidence 92 per 100,000 live born infants). Compared with infants with hearing loss who were born during periods without screening, those born during screening periods were more likely to have the hearing loss confirmed before age 10 months (59 versus 38 percent) and to start intervention before age 10 months (56 versus 27 percent; odds ratio 2.4, 95% CI 1.0-6.0).

Language and developmental outcomes — Earlier diagnosis and intervention for permanent hearing loss in infants appears to improve language and developmental outcomes [2,15-19,26]. Earlier diagnosis allows for earlier introduction of hearing aids.

In a study of 120 children with bilateral permanent hearing loss identified from a large birth cohort in England, children whose hearing loss was confirmed by nine months of age had better receptive and general language abilities compared with those confirmed after nine months of age [15,16,20,25]. In subsequent follow-up reports, patients from this cohort who were identified before nine months had better reading and communication skills than those diagnosed after nine months of age through adolescence [15,17].

Population Reference No. 1

Significant permanent hearing loss is a common disorder at birth and can lead to delayed language development, difficulties with behavior and psychosocial interactions, and poor academic achievement. Detection of hearing loss during infancy can initiate intervention resulting in improved language, cognitive, behavioral, and academic outcomes.

Suplemental Information

https://www.infanthearing.org/legislative/docs2022/statutes/PR_Legislation.pdf

Early Hearing Detection & Intervention Contacts:

References

1.Current Procedural Terminology , American Medical Association, 2022

2.https://www.uptodate.com/contents/screening-the-newborn-for-hearing-loss?search=Neonatal%20Auditory%20Screening&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

3.https://www.infanthearing.org/legislative/mandates.html#puertorico

Codes

Policy History

Payment Policy Guidelines

Administrative Evaluation

Triple-S, Inc. considers for basic payment (outside of the per-diem contracted with the hospital). These codes do not imply a coinsurance payment by the insured.

A single code will be paid per insured.

The repetition of the test, when the result so requires, is included in the rate initial. Hospitals are required to provide the service.

economic impact

Interqual Criteria

Policy Categorization