Page 2433

(3) the purchase of a hearing item that exceeds a limit under 7 AAC 115.530;

(4) a payment request that exceeds the maximum allowable payment for a hearing item;

(5) a customized hearing aid;

(6) a monaural hearing aid or binaural hearing aid for which a payment rate has not been established;

(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:

(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;

(B) a hearing aid;

(C) a hearing aid accessory;

(D) a hearing aid supply;

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

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

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

(A) determined that the service is medically necessary;

(B) conducted a clinical assessment of the recipient; and

(C) prepared a treatment plan. (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. (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) is necessary to replace a hearing item that is under repair;

(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