Alliance Health Cochlear Implant Coverage Update

Coverage Criteria

Cochlear Implant Initial Coverage

Covered when ALL of the following are met

Cochlear implant general criteria: 1. Device used according to the U.S. Food and Drug Administration (FDA) labeled indications; 2. No contraindications for the surgery; 3. The personal physician or otolaryngologist documents that the beneficiary has realistic expectations of device performance and ability to participate in a program of aural rehabilitation; 4. Confirmed diagnosis of severe to profound (>= 70 dB HL) sensorineural hearing loss in the ear to be implanted (exception: documented auditory neuropathy spectrum disorder with poor word recognition despite better thresholds); 5. Beneficiary is free of middle ear infection, has an accessible and structurally sound cochlear lumen for implantation, and is free of lesions in the auditory nerve and acoustic areas of the central nervous system.>= 70 dB HL

Documented in health record

Hearing Aid Trial / Evaluation Requirements

Covered when ALL of the following are met (age-specific)

Ages 12 months to 20 years: Beneficiary has limited benefit from at least a three-consecutive month trial of appropriately fitted hearing aids unless radiologic cochlear ossification or obstruction on CT scan waives the trial; limited benefit defined as <= 40% correct on an age-appropriate speech recognition test in the ear to be implanted.3 months; <= 40% speech recognition

Waiver allowed for cochlear ossification on CT

Age >=21 years: Beneficiary has an appropriate hearing aid evaluation completed with an appropriate hearing aid fitting trialed by a licensed audiologist.

Auditory Brainstem Implant

Covered when ALL of the following are met

ABI criteria: a. Beneficiary diagnosed with neurofibromatosis type 2; b. Beneficiary is undergoing bilateral removal of auditory nerve tumors with anticipated complete deafness from surgery OR has had bilateral auditory nerve tumors removed and is now bilaterally deaf; c. The FDA-approved device complies with FDA indications for use; d. There are no contraindications for the surgery.

Applies to beneficiaries 12 through 20 years of age

Upgrades and Maintenance

Replacement of existing internal cochlear implant covered when ANY of the following criteria is met

Upgrades and maintenance: a. The currently used component is no longer functional and cannot be repaired and there is no evidence of abuse or neglect; b. The currently used component renders the beneficiary unable to adequately or safely perform age-appropriate activities of daily living; c. The current technology has been made obsolete by the manufacturer.

External component requirements are addressed in Policy 13A

Contralateral Cochlear Implant

Covered after successful placement of original implant when ALL of the following are met

Contralateral implant prerequisites: a. Demonstrated successful usage of the (first) device; b. Active participation in an appropriate auditory-based intervention program; c. Active participation in an appropriate educational program; d. Radiographic evidence that contralateral cochlea and nerves are present; e. Demonstration by the beneficiary or family of the ability to care for the equipment needs of two devices; f. No evidence of severe physical, psychomotor, or cognitive delays; AND g. At least ONE of: 1) continued usage of a hearing aid has been unsuccessful if residual hearing is present; 2) the first side device is non-functional for medical or surgical reasons and replacement surgery is not an option; 3) the first side is suspected of having a device failure but still provides some beneficial auditory input; 4) the beneficiary develops significant delayed-onset visual impairment.

Applies to beneficiaries 12 months and older; considered case-by-case

Simultaneous Bilateral Cochlear Implants

Simultaneous bilateral cochlear implants are covered ONLY when at least one of the following is present

Simultaneous bilateral indications: a. Clear evidence of ongoing bilateral cochlear ossification or fibrosis from previous meningitis or cochlear inflammation; OR b. Significant bilateral visual impairment present or expected to develop (e.g., Usher's syndrome).

Contralateral Cochlear Implant

Covered when ALL of the following are met:

Primary requirements: a. Demonstrated successful usage of the device; b. Active participation in an appropriate auditory-based intervention program; c. Active participation in an appropriate educational program; d. Radiographic evidence that contralateral cochlea and nerves are present; e. Demonstration by the beneficiary or family of the ability to care for the equipment needs of two devices; f. No evidence of severe physical, psychomotor, or cognitive delays; AND g. When at least ONE of the following applies: 1) continued usage of a hearing aid has been unsuccessful if residual hearing is present; 2) the first side device is non-functional for medical or surgical reasons and replacement surgery is not an option; 3) the first side is suspected of having a device failure but still provides some beneficial auditory input; or 4) the beneficiary develops significant delayed-onset visual impairment.

Prior approval required; include date of initial implant, documentation of successful aural rehabilitation/use, and reason for contralateral implant

Simultaneous Bilateral Cochlear Implants

Covered ONLY when one of the following is present:

Simultaneous bilateral implant indications: a. Clear evidence of ongoing bilateral cochlear ossification or fibrosis from previous meningitis or cochlear inflammation; OR b. Significant bilateral visual impairment present or expected to develop (e.g., Usher's syndrome).

Must meet Subsection 3.2.6 and obtain prior approval

Diagnostic Analysis and Programming

Postoperative activation, evaluation, and programming covered as separate procedures when:

Programming coverage: a. Cochlear implant programming covered for beneficiaries 12 months of age and older; b. Auditory brainstem implant programming covered for beneficiaries 12 through 20 years of age; and c. No prior authorization required for postoperative diagnostic analysis and programming; health record must contain date of surgery and status of analysis/programming.

Refer to Subsection 5.1.7

Auditory Brainstem Implant

Prior approval required and must document ALL of the following:

ABI prior approval requirements: a. Beneficiary is 12 through 20 years of age; b. Diagnosis of neurofibromatosis type 2; and c. Either is undergoing bilateral removal of auditory nerve tumors with anticipated complete deafness from surgery OR has had bilateral auditory nerve tumors removed and is now bilaterally deaf.

Health record documentation must be submitted with the prior approval request

Upgrades and Maintenance

Prior approval required for upgrade/maintenance of internal components when ANY of the following are met:

Upgrade/Maintenance indications: a. Beneficiary's response to existing component(s) is inadequate to the point of interfering with activities of daily living; b. Component(s) are no longer functional; c. Device has been made obsolete by the manufacturer.

Health record documentation required with prior approval request

Medicaid/EPSDT does not require coverage for services that are unsafe, ineffective, experimental or investigational, or that are not generally recognized as accepted medical practice. Providers requesting coverage for beneficiaries under 21 must still document medical necessity according to EPSDT standards; however, interventions meeting the exclusions above are not covered.

Cochlear implantation will not be covered when any of the following contraindications are present: lesions of the central auditory pathway, lesions of the eighth cranial (acoustic) nerve or brain stem; active or chronic external or middle ear or mastoid infections, or tympanic membrane perforation; cochlear ossification that prevents electrode insertion; or absence of cochlear development on imaging. In addition, Medicaid does not cover bilateral cochlear implants during the same or a subsequent operative session except as allowed under the policy subsection that defines simultaneous bilateral implantation.

Providers billing for cochlear or auditory brainstem implant services must meet Medicaid qualifications for participation, maintain a current and signed DHHS Provider Administrative Participation Agreement, and bill only for services within the scope of their clinical practice as defined by their licensing entity.

Medicaid covers procedures, products, and services only when they are individualized, specific, and consistent with the beneficiary's confirmed diagnosis, not in excess of the beneficiary's needs, and can be safely furnished. Services that are primarily for convenience, not individualized, or where an equally effective, more conservative, or less costly statewide option exists are not considered medically necessary and are excluded from coverage.

Upgrades to an otherwise functioning external cochlear implant system that are undertaken solely to achieve an aesthetic improvement (for example, substituting smaller-profile external components or changing processor style) are not medically necessary and are not covered by Medicaid.

Coding

Procedure/CPT/HCPCS codes mentionedmixed

S2235	Physicians (listed in policy text)
69949	Physicians (listed in policy text)
69930	Simultaneous bilateral cochlear implants billed with modifier 50
92602	Speech and language/hearing related CPT (policy maps 92602 = 92603 / 92604 context)
92603	Referenced equivalent to 92602 in document
92604	Referenced equivalent to 69949 in document
92640	Billed as 1 unit = 1 hour

ICD-10 CodesICD-10

H90.A21	ICD-10 code listed
H90.A22	ICD-10 code listed
H90.3	ICD-10 code listed
H90.41	ICD-10 code listed
H90.42	ICD-10 code listed
Q85.02	ICD-10 code listed

Revenue CodesRevenue

RC 278

Revenue code

inv-20: Severe to profound sensorineural hearing loss — >= 70 dB HL

Threshold>= 70 dB HL (severe to profound sensorineural hearing loss)

ApplicabilityRequired for cochlear implant coverage in the ear to be implanted

ExceptionAuditory neuropathy spectrum disorder may be an exception when thresholds are better but word recognition is poor

inv-21: Limited benefit from amplification — <= 40% correct on age-appropriate speech recognition in the ear to be implanted

DefinitionLimited benefit from amplification is defined as <= 40% correct on an age-appropriate speech recognition test in the ear to be implanted

Age range relevance

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior approval is required for cochlear implants, auditory brainstem implants, upgrades/maintenance, contralateral and simultaneous bilateral implants except where specifically noted below. Routine unilateral cochlear implants that meet the coverage criteria in Subsection 3.2.2 do NOT require prior approval. Providers must follow EPSDT guidance: beneficiary age under 21 does not remove prior approval requirements where applicable and EPSDT information is available on the NCTracks and Medicaid EPSDT web pages.

Routine unilateral cochlear implant meeting Subsection 3.2.2: no prior approval required
Auditory brainstem implant: prior approval required with supporting documentation
Upgrades and internal component maintenance: prior approval required
Contralateral cochlear implant: prior approval required with specified documentation
Simultaneous bilateral cochlear implants: prior approval required

Background

A cochlear implant is an electronic medical device with external and internal components that bypass damaged cochlear hair cells to electrically stimulate auditory nerve fibers, restoring some ability to perceive sound and understand speech. Postoperative activation, programming, and participation in aural rehabilitation are required for benefit. Auditory brainstem implants are a related modification in which the stimulating electrode is placed directly into the brain and are indicated only in specific circumstances (for example, neurofibromatosis type 2 with bilateral auditory nerve tumor removal).

Definitions

inv-37: Auditory Brainstem Implant (ABI) — Definition: modification of cochlear implant with electrode placed in brain

DefinitionAn auditory brainstem implant (ABI) is a modification of the cochlear implant in which the stimulating electrode is placed directly into the brain.

Indications contextUsed in specific clinical circumstances (see ABI coverage criteria) and requires postoperative activation, programming, and rehabilitation

Relation to cochlear implantABI differs from cochlear implant by electrode placement on the brainstem rather than within the cochlea

inv-38: Cochlear implant — Definition: electronic medical device with external and internal parts to restore hearing/speech perception

DefinitionA cochlear implant is an electronic medical device with external and internal parts designed to restore some ability to perceive sounds and understand speech by stimulating remaining cochlear nerve fibers electrically.

OpenPayer

Cochlear and Auditory Brainstem Implants

Coverage Criteria

Coding

Provider Actions & Prior Authorization

Background

Definitions