A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture and amplify sound. Cochlear implant devices are available in single channel and multi-channel models. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are profoundly hearing impaired.
Coverage is subject to the specific terms of the member’s benefit plan.
Unilateral or bilateral cochlear implantation of a U.S. Food and Drug Administration (FDA) approved cochlear implant device may be considered medicallynecessary when ALL of the following criteria have been met:
- Individuals greater than or equal to 12 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 (8th) 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.)
In addition, auditory training and basic guidance (e.g., fitting external parts, programming the processor, etc.) performed during the postoperative period may be eligible for separate reimbursement when coverage for the cochlear implantation has been established.
Cochlear implantation is considered not medically necessary when provided for any other diagnosis other than the conditions referenced above.
Cochlear implantation is considered experimental/investigational and, therefore, non-covered as a treatment for individuals with unilateral hearing loss with or without tinnitus. Scientific evidence does not support the use of cochlear implantation for unilateral hearing loss.