Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Unilateral or bilateral cochlear implantation of a United States Food and Drug Administration (U.S. FDA) approved cochlear implant device may be considered medically necessary when
ALL
of the following criteria have been met:
-
Individuals greater than or equal to nine (9) months of age with bilateral severe to profound pre-or post-lingual (sensorineural) hearing loss defined as a hearing threshold of pure-tone average of 70 decibels (dB) hearing loss or greater at 500 hertz (Hz), 1,000 Hz, and 2,000 Hz, and have shown limited or no benefit from hearing aids. The age of the recipient at the time of implantation should be consistent with the FDA guidelines for the specific implant used;
and
-
Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
and
-
Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
and
-
No medical contraindications to cochlear implantation (including but not limited to active middle ear infection, deafness due to lesions of the eighth (8
th
) cranial nerve or brainstem, and absence of cochlear development).
Bilateral cochlear implantation may be considered medically necessary when it has been determined that the alternative of unilateral cochlear implant plus hearing aid in the contralateral ear will not result in a binaural benefit; (i.e., in individuals with hearing loss of a magnitude where a hearing aid will not produce the required amplification.)
Unilateral Sensorineural Hearing Loss
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
A traditional cochlear implant FDA approved for the treatment of single side profound sensorineural hearing loss or asymmetrical hearing loss may be considered medically necessary for when the individual meets
ALL
of the following criteria
:
-
Age greater than or equal to twelve (12) months;
and
-
Obtains limited benefit from an appropriately fitted unilateral hearing aid in the ear to be implanted;
and
-
at least one (1) month experience wearing a contralateral routing of signal (CROS) hearing aid or other relevant non implantable device;
and
-
Any
ONE
of the following:
-
profound sensorineural hearing loss in one ear and normal hearing or mild sensorineural hearing loss in the other ear (i.e., single sided deafness [SSD]);
or
- profound sensorineural hearing loss in one ear and mild to moderately severe sensorineural hearing loss in the other ear, with a difference of at least 15 dB in pure tone averages (PTAs) between ears (i.e., asymmetric hearing loss [AHL]).
Cochlear implantation is considered not medically necessary when provided for any other diagnosis other than the conditions referenced above.
Procedure Codes
| 69930 | 92601 | 92602 | 92603 | 92604 | 92622 | 92623 |
| 92626 | 92627 | 92630 | 92633 | L8614 | L8615 | L8616 |
| L8617 | L8618 | L8619 | L8621 | L8622 | L8623 | L8624 |
| L8625 | L8627 | L8628 | L8629 | L8699 |
