V5264 Ear mold/insert

Ear mold/insert, not disposable, any type

Medically Unlikely Edits (effective October 1, 2026)

Medicare pricing for V5264

Physician Fee Schedule (CY 2026, RVU26D)

Status N: non-covered service.

Payer policies and prior authorization for V5264

3 of 3 payer prior-auth lists that name V5264 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Rocky Mountain Health Plans, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross Blue Shield of Arizona (AZ Blue)Federal Employee Program (FEP)AZprior auth under conditionsFEP Standard and Basic onlySep 1, 2026Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026)
Rocky Mountain Health PlansRocky Mountain Health Plans CHP+COprior auth requiredOct 1, 2026Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026
UnitedHealthcare Community PlanUnitedHealthcare Community Plan of KentuckyKYprior auth requiredJul 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026

Payer coverage policies that name V5264

V5264 appears in 6 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Premera Blue Cross, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaBone-Anchored Hearing Aids (0403)listed, no stance (range V5008-V5299)Jul 22, 2026payer document
AetnaTinnitus Treatments (0406)not covered (range V5010-V5267)Jul 10, 2026payer document
Blue Cross & Blue Shield of MississippiProsthetics (L.1.04.401)covered if criteria are metpayer document
Blue Cross & Blue Shield of Rhode IslandHearing Aid Coveragenot coveredJan 1, 2026payer document
Premera Blue CrossHearing Aids (Excludes Implantable Devices)
Page | 8 of 19 | ∞		listed, no stanceSep 1, 2026payer document
UnitedHealthcareHearing Aids and Devices Including Wearable, Bone-Anchored, and Semi-Implantable (for Louisiana Only) (CS052LA.O)
Fitting and Testing of Hearing Aids		listed, no stanceAug 1, 2025payer document

Recent prior-auth changes

  • Oct 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Apr 1, 2026: PA removed, UnitedHealthcare Community Plan
  • Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in ND, NE, OH, VA, WV.

  • CO: $56.05 (health_first_colorado), effective Jul 1, 2026
  • FL: $18.13 (hearing, non-facility), effective Apr 6, 2026
  • IL: $46.57 (dme), effective Jan 1, 2026
  • IN: $38.90 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
  • KS: $20.25 (default, Exempt Physician), effective Jan 1, 2002
  • KY: $40.00 (audiology), effective Oct 16, 2003
  • LA: $57.78 (dme), effective Jul 1, 2012
  • MS: $18.15 (comprehensive), effective Oct 1, 2003
  • ND: $79.05 (dme), effective Aug 1, 2026
  • NE: $52.17 (hearing_aid), effective Jul 1, 2024
  • NY: $30.30 (hearing_aid, facility), effective Jul 1, 2026
  • OH: $25.46 (dme), effective Jan 1, 2024
  • OK: $46.82 (dme), effective Aug 1, 2020
  • TX: $40.76 (audiologist, Audiologist), effective Oct 1, 2013
  • VA: $35.00 (medical), effective Jan 1, 2004
  • VT: $40.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $38.87 (hearing_aids), effective Jul 1, 2026
  • WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.