Why Hearing Aids Are Denied, and the Three-Part Appeal That Sometimes Wins

Cost of one pair of mid-tier prescription hearing aids at a Tampa audiology clinic in early 2026: $4,890. Cost the patient, a retired postal worker on Original Medicare with no Advantage plan, was told she would pay: the full $4,890. Cost a neighbor of hers, on a Florida Medicare Advantage plan with a supplemental hearing benefit, paid for a comparable pair the previous year: $1,200. Cost a different neighbor, who had purchased an over-the-counter set at a national pharmacy chain under the FDA's 2022 OTC hearing aid rule, paid: $499. Cost the postal worker's audiogram, billed to Medicare Part B with a physician referral and documented as diagnostic: $0 after deductible. The audiogram was covered. The hearing aids it diagnosed she needed were not.

This is the most common cost structure in American hearing health: the diagnostic work is largely covered, the device that fits the diagnosis is largely not, and the gap is policed by a 1965 statutory exclusion that has outlived almost every clinical rationale offered for it. The Social Security Amendments of 1965, which created Medicare, included an exclusion of "hearing aids and examinations therefor" at what is now codified as 42 USC 1395y(a)(7). The exclusion was a budgetary line drawn at the program's creation. It remains the law. Original Medicare does not cover hearing aids. Medicare Advantage plans may offer supplemental hearing benefits as a plan-design choice. Commercial coverage varies widely by state and by plan. Pediatric coverage in a small but growing number of states is mandated by statute. Veterans' coverage under the VA is broad. TRICARE has its own framework. The patchwork is the policy.

This article walks through the federal exclusion and its narrow exceptions, the Medicare Advantage supplemental-benefit landscape, the state-by-state commercial mandate map, the cochlear implant pathway (which is governed by separate rules), and the three-part appeal that sometimes recovers coverage where it appears to be foreclosed. The article does not assert that hearing aid denials are easy to overturn. They are among the hardest. The point is to be precise about which denials have appeal-grade openings and which do not.

What 42 USC 1395y(a)(7) actually says, and what it does not say

The federal Medicare hearing aid exclusion is one of a handful of statutory exclusions written into the 1965 statute alongside cosmetic surgery, custodial care, and routine dental care. The text reads, in pertinent part, that no payment may be made for "hearing aids or examinations therefor." Two features of the language matter for appeal posture.

The first is the scope of "examinations therefor." CMS has interpreted this phrase to exclude routine hearing aid fitting examinations but not to exclude diagnostic audiology services ordered by a physician to evaluate hearing loss for medical purposes. CMS Manual System Pub 100-02, Chapter 15, distinguishes diagnostic audiology services (covered when physician-ordered for diagnosis of medical conditions) from routine hearing evaluations for hearing-aid fitting (not covered). The distinction is the leverage point for many initial appeals where a billed audiogram has been denied.

The second is the scope of "hearing aids." The statute does not define the term, and CMS has historically treated cochlear implants and bone-anchored hearing devices differently from conventional air-conduction hearing aids. Cochlear implants are covered under Medicare Part B as prosthetic devices under separate Medicare National Coverage Determination 50.3, with specific medical-necessity criteria. Bone-anchored hearing devices have similar prosthetic-device classification in some scenarios. The conventional hearing aid that amplifies sound for delivery through a normal-functioning ear canal is excluded; a surgically implanted device that bypasses or replaces a non-functioning conductive or sensorineural pathway is treated as a prosthetic and covered.

The line between "hearing aid" and "prosthetic device" is the most consequential medical-policy line in this field. Where the patient's hearing loss is severe enough and structurally configured such that a cochlear implant or bone-anchored device is clinically indicated, federal coverage opens in a way it does not for a conventional hearing aid.

The Medicare Advantage supplemental benefit landscape

Medicare Advantage plans, regulated under 42 CFR Part 422, are permitted to offer supplemental benefits that go beyond Original Medicare's coverage scope. Hearing benefits are among the most common supplemental offerings. The 2024 KFF analysis of Medicare Advantage benefit design found that more than 90 percent of Medicare Advantage plans included some form of hearing benefit, though the scope and dollar value vary widely.

Three caveats determine whether the benefit actually delivers coverage. The first is the allowance cap. Most MA hearing benefits operate as a fixed dollar allowance applied against the device cost, often $500 to $2,500 per device or per pair per year or per two-year cycle. The patient pays the gap. The second is the network constraint. Many MA hearing benefits require the use of a contracted hearing-services administrator (commonly TruHearing or NationsHearing), with no out-of-network coverage. A patient who has selected an out-of-network audiologist is excluded. The third is the device-type constraint. Several MA benefits cover only specific device tiers or technology levels.

Denials of MA hearing benefits typically take one of three forms: network-administrator denial, device-tier exclusion, or medical-necessity dispute for cochlear implants and bone-anchored devices. The appeal route runs through the standard 42 CFR Part 422 Subpart M process: 60-day Level 1 reconsideration, auto-forward to the IRE at Level 2, ALJ at Level 3, Medicare Appeals Council at Level 4, federal District Court at Level 5.

The state commercial-mandate map

Commercial hearing aid coverage outside Medicare is governed by state insurance law, employer plan design, and ACA essential health benefits (which do not federally require hearing aid coverage for adults). State mandates vary significantly. As of the 2025 reporting year, approximately 24 states have some form of pediatric hearing aid coverage mandate, with a smaller subset requiring coverage for adults.

The pediatric mandates typically require coverage of hearing aids for children under a specified age (often 18 or 21), at a specified replacement cycle (often every three years), with a specified dollar maximum or with no cap. The adult mandates are rarer and typically more limited. The specifics depend on the state. The state insurance commissioner is the authoritative source, indexed at content.naic.org/consumer.htm.

ERISA self-funded plans are preempted from state insurance mandates under 29 USC 1144. A child whose parent works for a self-funded employer in a mandate state does not benefit from the mandate. Fully insured group plans and individual ACA plans in mandate states are subject to the mandate; whether the plan actually applies it correctly is the operative question for many denials.

The 2022 FDA OTC hearing aid rule

The FDA's August 2022 final rule, codified at 21 CFR Part 800 Subpart H, established a new regulatory category for over-the-counter hearing aids for adults with perceived mild to moderate hearing loss. The rule made certain hearing aids available without a medical evaluation or audiologist fitting, brought OTC hearing aids into mainstream retail channels including pharmacies and consumer electronics retailers, and dramatically reduced the price floor for entry-level hearing assistance.

The OTC framework does not directly affect coverage of prescription hearing aids, but it changes the appeal landscape in two ways. First, the OTC option provides a real low-cost alternative for patients with mild to moderate loss, which affects how denials should be triaged: a denial that leaves a $4,890 prescription device uncovered is not the same as a denial that leaves the patient without any access to hearing assistance. Second, the OTC framework has prompted some carriers to position prescription hearing aids as a higher tier of care subject to medical-necessity demonstration. A denial citing "OTC alternative available" is not the end of the inquiry; the appeal should establish why the patient's hearing loss, by audiometric configuration and severity, is outside the OTC indication scope.

Exhibit 1: Coverage by program, in summary

The picture is easier to hold in a single table.

| Program | Hearing aid coverage | Cochlear implant coverage | Diagnostic audiology | |---|---|---|---| | Original Medicare (Parts A and B) | Excluded by statute | Covered as prosthetic device under NCD 50.3 with medical-necessity criteria | Covered when physician-ordered for diagnosis | | Medicare Advantage | Supplemental benefit common, allowance-capped | Covered under NCD 50.3 (binding on MA plans per 42 CFR 422.101) | Covered | | TRICARE | Covered for active-duty service members; conditional for retirees and dependents | Covered with medical-necessity criteria | Covered | | VA | Covered for eligible veterans (broad coverage) | Covered | Covered | | Medicaid (state-by-state) | Variable; some states cover, many do not | Generally covered when medically necessary | Generally covered | | Commercial fully insured | State mandate may apply; usually pediatric | Generally covered as prosthetic with medical-necessity criteria | Generally covered | | Commercial self-funded ERISA | Plan design dependent; state mandates preempted | Plan design dependent | Plan design dependent | | OTC consumer market | Available without prescription for adults; not insurance-related | n/a | n/a |

Action title for designer: "The federal exclusion is narrow but absolute. Every other coverage source layered on top of Medicare is partial, conditional, or program-specific. The first job of the appeal is to identify which layer the patient is actually in."

Exhibit 2: The cochlear implant pathway and its medical-necessity criteria

Cochlear implants are governed by a distinct regulatory framework that opens federal coverage where conventional hearing aids cannot. The medical-necessity criteria under Medicare NCD 50.3 are documented and replicable.

| Criterion | Source | Documentation needed | |---|---|---| | Bilateral severe to profound sensorineural hearing loss | Audiologic evaluation | Audiogram with pure-tone thresholds, speech audiometry | | Limited benefit from appropriately fit hearing aids | Aided speech recognition testing | Documented hearing aid trial period with sentence-recognition testing | | Word recognition score at or below specified threshold | AzBio sentence testing or equivalent | Audiologist documentation, validated test | | Cognitive ability and motivation to use device | Multidisciplinary evaluation | Audiology, otolaryngology, sometimes psychology | | Absence of medical contraindications | Otolaryngologic evaluation | Otolaryngologist documentation | | Realistic expectations | Counseling documentation | Patient/family counseling notes |

Action title for designer: "When the audiometric configuration supports cochlear implant candidacy, the federal coverage door opens that the conventional hearing aid door does not. The medical-necessity criteria are public and the documentation pathway is well established."

Exhibit 3: State pediatric hearing aid mandates (illustrative)

The pediatric mandates as of the 2025 reporting year are summarized below. Statutory language controls in each state; the state insurance commissioner is the authoritative source.

| State | Age cap | Replacement cycle | Per-ear or per-device cap | |---|---|---|---| | Arkansas | Under 18 | Every 3 years | Approximately $1,400 per ear | | Colorado | Under 18 | Every 3 years | No cap (limited to medically necessary) | | Connecticut | Under 13 (with extensions) | Every 24 months | Approximately $1,000 per ear | | Delaware | Under 24 | Every 3 years | Approximately $1,000 per ear | | Georgia | Under 18 | Every 4 years | Approximately $3,000 per ear | | Illinois | Under 18 | Every 36 months | No statutory cap | | Indiana | Under 18 | Every 3 years | No statutory cap | | Kentucky | Under 18 | Every 36 months | Approximately $1,400 per ear | | Louisiana | Under 18 | Every 36 months | Approximately $1,400 per ear | | Maine | Under 18 | Every 36 months | Approximately $3,000 per ear | | Maryland | Under 18 | Every 36 months | Approximately $1,400 per ear | | Massachusetts | Under 21 | Every 36 months | $2,000 per ear | | Minnesota | Under 18 | Every 3 years | No statutory cap | | Missouri | Under 18 | Every 36 months | Approximately $1,400 per ear | | New Hampshire | Under 18 | Every 60 months | $1,500 per ear | | New Jersey | Under 15 | Every 24 months | $1,000 per ear | | New Mexico | Under 18 | Every 36 months | Approximately $2,200 per ear | | North Carolina | Under 22 | Every 3 years | No statutory cap | | Oklahoma | Under 18 | Every 4 years | Approximately $1,400 per ear | | Oregon | Under 26 (for student dependents) | Per medical necessity | No statutory cap | | Rhode Island | Under 19 | Every 36 months | $1,500 per ear | | Tennessee | Under 18 | Every 3 years | Approximately $1,000 per ear | | Texas | Under 18 | Per medical necessity | Per medical necessity | | Wisconsin | Under 18 | Every 3 years | No statutory cap |

Action title for designer: "Twenty-four states protect children. Almost none protect adults. Self-funded ERISA plans bypass the state floor entirely. The first appeal question for a pediatric denial is which floor actually applies."

The three-part appeal

The structural denial framework in hearing aid coverage is narrow enough that the appeals that recover coverage typically follow one of three patterns.

The first part is the diagnostic-versus-fitting distinction. Where the denial relates to a billed audiogram or audiologic evaluation, the appeal establishes that the service was physician-ordered diagnostic audiology under CMS Manual Pub 100-02 Chapter 15, not a hearing-aid-fitting examination. The CPT code, the ordering physician's referral, and the diagnostic indication on the order are the principal documentation. Many of these denials are coding-system overrides that reverse on a clean appeal.

The second part is the prosthetic-device classification. Where the patient's hearing loss configuration supports cochlear implant or bone-anchored device candidacy, the appeal moves the case from "hearing aid" (excluded) to "prosthetic device" (covered with medical-necessity criteria). The clinical evidence stack is the audiologic evaluation, aided speech-recognition testing demonstrating limited hearing aid benefit, otolaryngologic clearance, and the multidisciplinary candidacy evaluation. The NCD 50.3 criteria are publicly available; the appeal demonstrates each one.

The third part is the layered coverage source. For MA plan denials, the appeal runs through the Subpart M reconsideration framework with the supplemental-benefit Evidence of Coverage as the principal contract document. For commercial pediatric denials in mandate states, the appeal anchors on the state mandate. For commercial adult denials, the medical-necessity argument is harder and depends on plan-specific language. For TRICARE, VA, and Medicaid, each program has its own appeal route and the appeal letter is drafted for that route.

Most adult hearing aid denials in Original Medicare and in non-mandate commercial coverage do not have a high-likelihood reversal path through the conventional-hearing-aid framing. The honest assessment is that the federal exclusion is durable. The recoverable cases are those that touch the cochlear implant pathway, the diagnostic audiology category, the MA supplemental benefit, the pediatric state mandate, or the TRICARE/VA/Medicaid frameworks. The appeal letter that wins is written against the framework that actually controls the patient's coverage, not against the federal exclusion in the abstract.

The procedural weight a self-prepared appeal carries

Hearing aid coverage runs on a five-framework patchwork (Original Medicare exclusion, Medicare Advantage supplemental benefits, commercial state mandates, TRICARE, VA, Medicaid) and the appeal that lands depends on identifying which framework actually controls and which of three appeal pathways (diagnostic-audiology distinction, prosthetic-device classification for cochlear/BAHA, or layered coverage source) fits. The mapped library Apellica has catalogued (more than two hundred carrier-by-denial-type cells, indexed at the bulletin level) each interpret the CMS Manual System Pub 100-02 Chapter 15 distinction differently in Medicare Advantage, and the 24 state pediatric mandates use materially different statutory language.

The cochlear implant pathway under NCD 50.3 requires the multidisciplinary candidacy evaluation, aided speech-recognition testing demonstrating limited hearing aid benefit, and otolaryngologic clearance. The 30-day document-request right under 29 CFR 2560.503-1(h)(2)(iii) compels production of the operative bulletin. Procedural exhaustion missteps foreclose external review.

The honest assessment is that adult hearing aid denials in Original Medicare and in non-mandate commercial coverage have low recovery odds. The recoverable cases (cochlear implant pathway, diagnostic audiology category, MA supplemental benefit, pediatric state mandate, TRICARE/VA/Medicaid) are the ones the appeal has to be written against.

The audiogram was covered. The hearing aids the audiogram diagnosed she needed were not. The exclusion is from 1965 and has outlived almost every rationale offered for it.

What separates a desk-prepared appeal from a self-prepared one

The senior-reviewer desk runs an internal index of more than two hundred carrier-by-denial-type cells that tracks hearing aid and cochlear implant coverage across all five frameworks. The desk knows which adult denials sit inside a durable federal exclusion and which carry an appealable foothold, and will tell a patient honestly when the math does not support filing.

Where the foothold exists (diagnostic audiology category, NCD 50.3 cochlear implant criteria, MA supplemental benefit Evidence of Coverage, pediatric state mandate, TRICARE/VA/Medicaid), same-day document-request letters go out with the correct CFR cite. Apellica's senior reviewers build the four-part evidence stack, plan-language citation, clinical facts including the audiometric configuration, peer-reviewed evidence including the ASHA and AAO-HNS guidance, regulatory hook, for every case. A senior reviewer reads every appeal before it goes out.

Initial review is free. There is no upfront fee. Patients are not asked to pay anything until the carrier reverses the denial.

Where to ask for help

The Hearing Loss Association of America, at hearingloss.org, runs a patient-advocacy network and publishes coverage-related resources. The American Speech-Language-Hearing Association, at asha.org, publishes guidance on diagnostic audiology coding and the cochlear implant evaluation pathway. The American Academy of Audiology, at audiology.org, is the audiology-society counterpart. The Cochlear Implant Awareness Foundation and the manufacturer-affiliated patient resources (Cochlear Americas, Advanced Bionics, MED-EL) provide candidate-evaluation information. State insurance commissioners are indexed at content.naic.org/consumer.htm. The SHIP network at shiphelp.org handles Medicare-related questions in every state. The VA's Audiology and Speech Pathology Service provides veteran-specific information. Apellica, at apellica.com, prepares evidence-based appeal letters for hearing aid and cochlear implant denials in all 50 states with no upfront fee.

What to do if you have a hearing aid denial right now

Most denials within the federal exclusion are durable. The recoverable cases live in the narrow but real categories above. Most patients leave the recoverable coverage on the table because identifying the right framework is more procedural work than they can take on.

The Tampa postal worker did not have a recoverable framework. The next Medicare Annual Election Period she shifted to an MA plan with a supplemental hearing benefit; the following spring her pair cost her $1,250 out of pocket instead of $4,890. The exclusion is durable. The patient's plan choice is not.

How Apellica engages a case

Apellica prepares the evidence-based appeal letter for hearing aid, cochlear implant, and diagnostic audiology denials in all 50 states, at every level of the internal and external appeal process. The patient or family member reviews and approves every word before submission and authorizes carrier communications under a HIPAA-compliant Assignment of Benefits. We are not a law firm. We are not a medical provider. We are not an insurance carrier. We are an independent administrative service that turns a denied claim into a properly documented appeal letter.

Our model is $0 upfront and a flat fee on successful recovery. If the appeal does not reverse, the patient owes nothing for the preparation work. Coverage extends to all 50 states, Medicare Advantage, commercial plans, TRICARE, VA, and Medicaid. A senior reviewer reads every case before it goes out.

About the author

About the author. Mark Henderson is a senior reviewer at Apellica, an independent appeal-preparation service for denied health-insurance claims. The office is at One World Trade Center, Suite 8500, New York, NY 10007. Apellica covers all fifty states. Apellica does not provide legal advice and is not a law firm. For questions: press@apellica.com, +1 (888) 777-6120, apellica.com.

References

• 42 USC 1395y(a)(7). Statutory exclusion of hearing aids and examinations therefor.
• CMS Manual System Pub 100-02, Chapter 15, Covered Medical and Other Health Services.
• Medicare National Coverage Determination 50.3, Cochlear Implantation.
• 42 CFR Part 422. Medicare Advantage program.
• 42 CFR 422.101. Standards for MA contracts (NCD/LCD application).
• 42 CFR 422.582. Medicare Advantage reconsideration deadline.
• 21 CFR Part 800, Subpart H. OTC hearing aid rule.
• FDA Final Rule, Medical Devices; Ear, Nose, and Throat Devices; Establishing Over-the-Counter Hearing Aids (August 2022).
• 29 USC 1144. ERISA preemption.
• 45 CFR 147.136. Internal claims and appeals and external review.
• 29 CFR 2560.503-1. ERISA claims procedure.
• KFF, Medicare Advantage 2024 Spotlight on Supplemental Benefits.
• Hearing Loss Association of America. hearingloss.org.
• American Speech-Language-Hearing Association. asha.org.
• American Academy of Audiology. audiology.org.
• NAIC Consumer Information Source. content.naic.org/consumer.htm.
• SHIP national directory. shiphelp.org.
• VA Audiology and Speech Pathology Service.