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Cochlear Implantation

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 22, 2019
Last Reviewed: November 14, 2019

Description

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.

Criteria

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:

  1. 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
  2. Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; and
  3. 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
  4. 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.

Procedure Codes

69930 92601 92602 92603 92604 92626 92627
92630 92633 L8614 L8615 L8616 L8617 L8618
L8619 L8621 L8622 L8623 L8624 L8625 L8627
L8628 L8629 L8699

Nucleus® Hybrid™ L24 Cochlear Implant System

Cochlear implantation with a hybrid cochlear implant/hearing aid device that includes the hearing aid integrated into the external sound processor of the cochlear implant (e.g., the Nucleus® Hybrid™ L24 Cochlear Implant System) may be considered medically necessary for individuals greater than or equal to 18 years who meet ALL of the following criteria:

  • Bilateral severe-to-profound high-frequency sensorineural hearing loss with residual low-frequency hearing sensitivity; and
  • Receive limited benefit from appropriately fit bilateral hearing aids; and
  • Have the following hearing thresholds:
    • Low-frequency hearing thresholds no poorer than 60 dB hearing level up to and including 500 Hz (averaged over 125, 250, and 500 Hz) in the ear selected for implantation; and
    • Severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz greater than or equal to 75 dB hearing level) in the ear to be implanted; and
    • Moderately severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz greater than or equal to 60 dB hearing level) in the contralateral ear; and
    • Aided consonant-nucleus-consonant word recognition score from 10% to 60% in the ear to be implanted in the preoperative aided condition and in the contralateral ear will be equal to or greater than the ear to be implanted but not greater than 80% correct.

Procedure Codes

9930 92521 92522 92523 92524 92626 92627
92630 92633 L8614 L8615 L8616 L8617 L8618
L8619 L8621 L8622 L8623 L8624 L8625 L8627
L8628 L8629 L8699

The following codes may be used for diagnostic purposes to assist the physician in assessing the individual’s ability to utilize residual hearing to design a management plan, monitor progress and measure outcome of management. The testing can assist in obtaining information necessary for the physician's medical evaluation or to determine the appropriate medical or surgical treatment. Testing frequency depends on the needs of each individual. Testing frequency may range from a single visit to numerous depending on the severity of the problem, complexity of the management plan and the individual’s progress.

Procedure Codes

92626 92627

Professional Statement and Societal Positions Guidelines

Center for Disease Control (CDC) – 2002

Individuals with cochlear implants are more likely to develop bacterial meningitis than individuals without cochlear implants. The bacteria Streptococcus pneumoniae (pneumococcus) causes most cases of meningitis in individuals with cochlear implants. Due to increased risk, the CDC recommends age appropriate pneumococcal vaccination for individuals who have or are candidates for cochlear implants.

Diagnosis Codes

H90.3 H90.5 H90.6 H90.8 H90.A21 H90.A22 Z96.21

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