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:
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.
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:
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.
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.