Minimum Hearing Loss Threshold (MHLT)

(1)

Minimum Hearing Loss Threshold (MHLT)

(Participants in the Voucher System) Determination 1997. As of 1 July 2010, clients whose 3 Frequency Average Hearing Loss is less than or equal to 23 dB in the ear being fitted, cannot proceed to fitting to that ear, nor can they be provided with an Alternate Listening Device, unless the client meets the exemption criteria (below).

In this document, a ‘minimal hearing loss’ is defined as a 3 Frequency Average Hearing Loss (measured at 0.5, 1 & 2 kHz) of less than or equal to 23 dB (ie, 3FAHL ≤ 23 dB). A degree of hearing loss does not on its own predict a need, benefit or outcome with respect to a fitting. Much depends on the nature of the hearing loss, the configuration of the hearing loss, the degree of communication difficulties experienced, and on the attitude, motivation and goals of the individual client.

Not all eligible voucher holders who attend for a hearing assessment are looking to proceed to a fitting. Some clients with a degree of hearing loss may not want or need a hearing aid. Consideration of Item 670 (rehabilitation without hearing aids) may be a suitable option for these clients.

Exemption Criteria to the Minimum Hearing Loss

Threshold

The Office of Hearing Services (the Office) recognises that some clients with a minimal degree of hearing loss may nonetheless demonstrate a clinical need for, and will benefit from, the provision of a hearing device. For this reason, a set of criteria for determining exemptions to the threshold has been established in legislative regulations.

Hearing practitioners must follow these criteria when assessing whether it is appropriate to fit or refit a client with minimal hearing loss within the context of the Australian Government Hearing Service Program (the Program). It is anticipated that only a small number of

clients with minimal hearing loss will meet the criteria and proceed to a fitting.

The criteria address significant aspects of rehabilitation and when considered together as a test battery, they will (a) maximise the likelihood of identifying those clients who are experiencing serious consequences from their hearing loss, and (b) maximise the chance of a successful rehabilitation outcome.

All voucher holders are subject to the following two criteria when determining exemptions to the threshold. Under the first criterion the client must meet at least one of four

conditions. Both criteria must be met for an exemption to apply.

1. One of the following conditions applies

a. Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz) which is equal to or greater than 40dB (ie, HFAHL ≥40dB.) OR

b. Client has tinnitus, where both the hearing loss and the tinnitus can be addressed through the use of an approved hearing device OR

c. Client has a visual impairment that cannot be corrected by treatment, and which reduces the client’s ability to see mouth movements OR

d. Client has previously been fitted with a hearing device under the voucher system, where the client can demonstrate consistent use of the previously fitted hearing device.

And

2. Client has a positive attitude and is motivated to wear a hearing device,

demonstrated through responses to the Wishes and Needs Tool. The client’s response to each of the individual questions on the Wishes and Needs Tool must attract a score of at least 2 on the scale, and the total score must be 5 or greater.

(3)

Guidelines for the Administration of the Minimum

Hearing Loss Threshold

Voucher clients must meet both exemption criteria in order to gain exemption from the Threshold. In order to proceed to a fitting, clients who meet the exemption criteria must meet the results required when assessing and fitting a hearing device –as outlined in the Hearing Rehabilitation Outcomes for Voucher Holders (HROs). The exemption criteria together with the results required in the HROs address significant aspects of rehabilitation and together will (a) maximise the likelihood of identifying those clients who are

experiencing serious consequences from their hearing loss, and (b) maximise the chance of a successful rehabilitation outcome.

Both Criterion 1 and Criterion 2 must be met.

Criterion 1

One of the following conditions applies

a) Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz)

which is equal to or greater than 40 dB (ie, HFAHL ≥40dB.) OR

b) Client has tinnitus , where both the hearing loss and the tinnitus can be

addressed through the use of an approved hearing device OR

c) Client has a visual impairment that cannot be corrected by treatment, and which

reduces the client’s ability to see mouth movements OR

d) Client has previously been fitted with a device under the voucher system, where the client can demonstrate consistent use of the previously fitted hearing device.

a) Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz)

which is greater than or equal to 40 dB (ie, HFAHL ≥40dB.).

1. Calculate the high-frequency average hearing loss, measured at 2, 3 & 4 kHz (HFAHL). If the HFAHL is greater than or equal to 40 dB then the client is a potential candidate for fitting.

2. If the HFAHL is LESS than 40 dB then the client is NOT considered a candidate for fitting under this criterion.

3. Note - where there is an air-bone gap in the high frequencies, check headphone placement/collapsing canals before calculating HFAHL.

b) Client has tinnitus, where both the hearing loss and the tinnitus can be

addressed through the use of an approved hearing device. As a condition

separate to hearing impairment, tinnitus cannot be the sole reason to provide

hearing aids to eligible clients. However, an exemption to the MHLT will be granted to clients with a minimal hearing loss for whom amplification serves to reduce or eliminate severe or constant tinnitus that affects quality of life. Fitting may proceed where amplification can be shown both to address the hearing loss and to reduce the tinnitus. The practitioner must be able to show through their documentation that aiding the client has had successful outcomes for both their hearing loss and

tinnitus relief.

In such cases, it will be necessary to document evidence of the severity of the tinnitus, using a tool such as the Tinnitus Reaction Questionnaire (TRQ), the Tinnitus Handicap Inventory (THI), the Assess Your Stress Inventory (eg Hari’s Stress Inventory), or the Stress Vulnerability Scale.

(4)

c) Client has a visual impairment that cannot be corrected by treatment, and

which reduces the client’s ability to see mouth movements. Erberi describes an

8-9 dB improvement when clients have access to visual cues. Minimal hearing loss clients with concurrent vision loss may therefore experience greater communication difficulties than minimal loss clients with good visual acuity, and are possible

candidates for fitting.

In such cases, it will be crucial to document evidence that amplification serves to improve audibility of speech, as required under the HROs.

Clients with more serious visual impairments should continue to be notified to the Office as Complex Clients.

d) Client has previously been fitted with a hearing device under the voucher system, where the client can demonstrate consistent use of the previously fitted hearing device.

For clients with minimal hearing loss previously fitted under the Program (with either

hearing aids or an Alternate Listening Device), practitioners must provide evidence that the client has consistently used a device previously fitted.

Documented evidence of consistent use may come from sources such as

• hours-of-use information from data logging

• repeated supply of replacement batteries and on-going minor repairs.

Additionally, evidence of benefit and satisfaction from the use of a listening device may be provided through responses to self-report outcomes questionnaires such as IOI-HAii

or HAUQ. And

Criterion 2

Client has a positive attitude and is motivated to wear a hearing device

From 1 July 2010, use of the Wishes and Needs Tool (WANT) is mandatory for all clients with a 3FAHL of less than or equal to 23 dB in the ear being fitted.

The WANT consists of the two questions as issued by the National Acoustic Laboratories on 1 July 2010. This tool is a client self-report instrument. Clients will answer the two questions, and their answers will be recorded as part of the client file. Wherever possible, clients should complete these questions without assistance from the practitioner or others to ensure that the answers reflect the clients’ own perspective on attitude and motivation. There should be no information included on the tool that might lead the client to a

particular score.

The WANT should be stored as part of the client file, either physically or electronically. The tool is simple, quick to apply and easy to score. The questions are intended to be administered towards the end of the assessment/reassessment appointment.

Dilloniii identified that clients who were motivated were more likely to be successful hearing aid wearers. In a 2005 survey of clients, analysis of client answers to two questions

correlated highly with device fitting outcomes. Information about clients’ readiness to accept hearing aids gives valuable information about fitting candidacy.

(5)

Clients who are identified as being unready to accept hearing aids, or whose responses indicate minimal communication difficulties, should not proceed to fitting.

The expectation is that practitioners operating under the Program, as in all clinical settings, will use a range of formal and informal approaches to assess clients’ attitude and

motivation towards rehabilitation and hearing device fitting.

In addition to the mandatory WANT attitude and motivation may be evaluated using questionnaires, or by informal questioning during the initial interview/history.

One example of informal questioning is that used by Goldstein and Stephens (1981)iv. Examples of questionnaires completed by the client prior to the initial appointment include

• Hearing Handicap Inventory for the Elderly (HHIE)v

• Denver Scale of Communication Function (DSCF)vi

Other Considerations

Asymmetrical Hearing Loss

Practitioners may fit clients with unaidable hearing in the poorer ear at their own discretion (eg with a CROS device) providing requirements against the Hearing Rehabilitation

Outcomes are met.

When a client has one ear with a 3FAHL (0.5, 1 & 2 kHz) above the 23 dB threshold and one ear with a 3FAHL equal to or below the 23 dB threshold (the better ear), then each ear needs to be evaluated independently.

In order to fit the better ear, the exemption and fitting HRO results must be met.

Monitoring and Compliance

Monitoring will include, but not be limited to, client surveys, targeted audits and clinical file reviews.

The Office Review and Audit

Files of all clients with minimal losses (those who are fitted as well as not fitted) will be subject to the usual Office review and audit processes. Reviews will focus on file

documentation relating to each of the above considerations as well as the final outcome for clients.

Documentation and Claiming Requirements

Documentation must be kept on file regarding all criteria for each client with a minimal hearing loss who is considered for device fitting. As with all fittings, claiming should not proceed if fitting has not achieved its purpose and is therefore unsuccessful.

Medicare e-claiming system

All providers are to enter the client’s recorded hearing loss into the Medicare e-claiming system. Providers who are found not to be entering this information into the Medicare e-claiming system will be targeted for audits conducted on Program client files to ensure their claiming practices are meeting their obligations as a service provider.

(6)

The Office will take action against providers who claim for a service under the Program for clients who do not meet the MHLT criteria. This action may include, but is not limited to, recovery of all funds claimed.

Manual claiming

If a manual claim is required for a client fitted under the MHLT criteria, include the client’s audiogram, a signed copy of the WANT tool (in the form as issued by NAL), and if

applicable, documentation showing how the client meets one of the four exemption criteria (i.e. a completed copy of a tinnitus questionnaire, a letter from a relevant professional documenting a client’s visual difficulties, etc).

Recording 3FAHL of 23.3 dB

As the closest whole number to 23.3 dB is 23 dB, it is appropriate to enter the client’s 3FAHL as 23 dB. When claiming electronically, proceed as per usual and ensure the audiogram on file corroborates that the client’s 3FAHLs are actually 23.3 dB. If claiming manually, include information on the manual claim cover sheet that the client’s 3FAHL is 23.3 dB and include a copy of the client’s most recent audiogram.

Contacting the Office Audiologists

Practitioners are welcome to contact the Office with enquiries about the content of this document, or to discuss individual cases. You should note however, that the Office audiologists are unable to grant any exemptions to the MHLT beyond those which are determined using the criteria outlined above.

References

i. Erber, NP. Hearing, Vision, Communication and Older People, Clavis Publishing (2002) ii. Cox RM, Alexander GC (2002) “The International Outcome Inventory for Hearing Aids

(IOI-HA) psychometric properties of the English version.” International Journal of Audiology 41(1) 30-35

iii. Denis Byrne Oration (2008), presented at Audiology Australia Conference, Canberra, 2008

iv. Goldstein and Stephens. Audiological Rehabilitation. Management Model 1, International Journal of Audiology 1981, 20(5), 432-452

v. Weinstein, BE, Spitzer, JB, Ventry, IM. Test-Retest Reliability of the Hearing Handicap Inventory for the Elderly. Ear and Hearing Oct 1986, Vol 7, Issue 5

vi. Kaplan, H, Feeley, MA, Brown, J. A modified Denver Scale Test-Retest Reliability. JARA Vol XI, 2, Oct 1978

Minimum Hearing Loss Threshold (MHLT)