Hearing Aid Insurance Claim Denied: How to Appeal and Get Coverage
Insurance denied coverage for hearing aids? Learn how to appeal hearing aid denials, what states mandate hearing aid coverage, how to use medical necessity arguments, and what rights children have under EPSDT.
Hearing Aid Insurance Claim Denied: How to Appeal and Get Coverage
Hearing aids can cost $3,000–$8,000 or more per pair, yet most US commercial health insurance plans exclude them — and many plans that nominally cover hearing aids apply such restrictive conditions that claims are routinely denied. However, hearing aid coverage mandates in many states, children's rights under Medicaid's EPSDT provision, and medical necessity arguments for certain types of hearing loss create more opportunities to appeal than many people realise.
Why Hearing Aid Claims Are Denied
Plan exclusion: The most common reason — many commercial health plans explicitly exclude hearing aids and hearing-related hardware. However, explicit exclusions can still be challenged in certain circumstances.
"Not medically necessary": Some insurers deny hearing aids on medical necessity grounds, arguing that the degree of hearing loss doesn't meet their threshold, or that hearing aids are not "necessary" in a medical sense.
Age restrictions: Some plans cover hearing aids for children but not adults, or cover them only for specific age ranges.
Frequency restrictions: Many plans that do cover hearing aids limit how often you can receive new aids (e.g., once every 3 or 5 years). Claims outside this frequency are denied.
Dollar cap: Plans may cover hearing aids up to a low dollar amount (e.g., $500/ear) — far below the actual cost — resulting in a partial denial that feels like a full denial.
Non-covered device type: Plans may cover basic hearing aids but deny claims for more technologically advanced aids recommended by the audiologist.
Provider credentialing issues: Claims from audiologists not credentialed with the insurer may be denied.
US State Hearing Aid Mandates
Many US states have passed laws requiring health insurers to cover hearing aids, particularly for children:
States with children's hearing aid mandates include: Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, and others
Key points about state mandates:
- Most state mandates focus on children under 18; fewer cover adults
- Coverage requirements vary widely (dollar amounts, device types, frequency)
- Self-insured ERISA plans are exempt from state mandates
- Determine whether your plan is fully insured (subject to state law) or self-insured (ERISA-governed, exempt from state mandates)
Children's Hearing Aid Rights Under Medicaid EPSDT
For children under 21 on Medicaid: EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requires states to cover any service that is medically necessary for a child's health — including hearing aids — even if the service is not included in the state's adult Medicaid benefit package.
If Medicaid or a Medicaid managed care plan has denied hearing aids for your child, cite EPSDT. This is one of the most powerful tools available for children's Medicaid claims.
Step-by-Step: Appealing a Hearing Aid Denial
Step 1: Identify the Specific Denial Reason
Review your insurer's denial:
- Is hearing aid coverage explicitly excluded?
- Is the denial based on medical necessity?
- Is the denial based on a frequency or dollar limit?
- Is the claim for a device type your plan doesn't cover?
Each scenario requires a different approach.
Step 2: Gather Audiological and Medical Evidence
- Audiologist's letter: Documenting the degree of hearing loss (audiogram), how it impacts daily functioning, and why the specific hearing aid recommended is the most appropriate for your condition
- Physician's letter: From your ENT or primary care physician supporting the medical necessity of hearing aids for your specific condition
- Audiogram results: Showing the severity and type of hearing loss
- For children: Audiologist's letter specifically addressing developmental and educational impact of untreated hearing loss
Step 3: Research Your State Mandate
Check whether your state has a hearing aid mandate and whether your plan is subject to it. If your state has a mandate and your plan is fully insured, cite the mandate specifically in your appeal.
Step 4: Make the Medical Necessity Argument
Even for plans with hearing aid exclusions, a strong medical necessity argument may work:
- Hearing loss meeting certain clinical thresholds is a medically diagnosed condition
- Untreated hearing loss is associated with cognitive decline, social isolation, depression, and safety risks
- Hearing aids are a medically prescribed device for a medical condition
- Cite clinical guidelines from the American Academy of Otolaryngology and the American Academy of Audiology
For severe or profound hearing loss, the medical necessity argument is particularly strong.
Step 5: Submit Your Appeal
Include in your appeal letter:
- Your audiologist's and physician's letters
- Your audiogram results
- Your state's hearing aid mandate (if applicable)
- Clinical guidelines supporting hearing aid coverage for your level of hearing loss
- For children on Medicaid: citation of EPSDT requirements
Step 6: Request External Review
After exhausting internal appeals, request external review. External reviewers apply clinical standards and are not bound by your insurer's internal criteria or plan exclusions.
Step 7: File a Regulatory Complaint
US: File with your state's Department of Insurance (if state mandate violation is involved) UK: File with the FOS (NHS hearing aids are free for qualifying conditions; private hearing aid insurance disputes go to FOS) Australia: File with PHIO or AFCA
Medicare and Hearing Aids
Traditional Medicare (Parts A and B) does NOT cover hearing aids. However:
- Medicare Advantage (Part C) plans are increasingly offering hearing aid benefits as supplemental coverage
- If your Medicare Advantage plan denies a hearing aid claim under their supplemental hearing benefit, you have Medicare Advantage appeal rights (including IRO review and ALJ hearing)
- Review your Medicare Advantage Evidence of Coverage for specific hearing aid benefit terms
VA (Veterans Affairs) Hearing Aid Coverage
Veterans with service-connected hearing loss receive free hearing aids through the VA. If the VA has denied hearing aid benefits to a veteran with documented hearing loss, the VA's appeals process (Notice of Disagreement, Board of Veterans' Appeals) applies.
Conclusion
Hearing aid insurance denials are common but frequently challengeable — especially for children covered by state mandates or Medicaid EPSDT, and for adults with severe hearing loss that clearly meets medical necessity criteria. Research your state's mandate, gather comprehensive audiological evidence, and don't accept the first denial as final. Use ClaimBack at claimback.app to generate a professional appeal letter for your hearing aid insurance denial.
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