CurrentAmbetter GeorgiaPolicy WA.CP.MP.502

Cochlear Implants

Customize your policy alerts

Sign up for Ambetter Georgia Policy WA.CP.MP.502 alerts

Get alerted when Policy WA.CP.MP.502 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity guidelines for unilateral and bilateral cochlear implant placement and coverage for Ambetter Georgia members/enrollees, aligned with Washington State Health Care Authority assessments and billing guidelines.

Policy Summary

PayerAmbetter Georgia

PolicyCochlear Implants

Policy CodePolicy WA.CP.MP.502

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization documenting that all medical necessity criteria (A–F) are met and include procedure coding (e.g., CPT 69930).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6core coverage criteria (A–F)

69930Referenced CPT

HCA HTAPrimary evidence

CP.MP.14Related policy

Cochlear Implant Coverage Criteria

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentAmbetter GeorgiaPolicy WA.CP.MP.502

Cochlear Implants

Customize your policy alerts

Sign up for Ambetter Georgia Policy WA.CP.MP.502 alerts

Get alerted when Policy WA.CP.MP.502 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Georgia

PolicyCochlear Implants

Policy CodePolicy WA.CP.MP.502

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization documenting that all medical necessity criteria (A–F) are met and include procedure coding (e.g., CPT 69930).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6core coverage criteria (A–F)

69930Referenced CPT

HCA HTAPrimary evidence

CP.MP.14Related policy

Cochlear Implant Coverage Criteria

Initial Cochlear Implant Coverage Criteria

Covered when ALL of the following are met

Primary coverage criteria

A: Bilateral severe to profound sensorineural hearing loss
B: Limited or no benefit from hearing aids
Cognitive ability and willingness to participate in an extensive auditory rehabilitation program
D: 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
E: No other contraindication for surgery
F: Device is used in accordance with FDA approved labeling

Any other contraindication for surgery or conditions that render the cochlea inaccessible, or that leave the auditory nerve or central auditory pathways nonfunctional, exclude candidacy for cochlear implantation. Examples include ongoing middle ear infection, anatomic obstruction of the cochlear lumen that prevents device insertion, or lesions of the auditory nerve and acoustic regions of the central nervous system that would preclude effective auditory stimulation.

Requests for cochlear implantation that do not meet ALL of the specified medical necessity criteria (A–F) are considered not medically necessary. Prior authorization documentation must demonstrate that each criterion has been satisfied before coverage will be approved.

Prior Authorization, Documentation, and Billing

Prior Authorization

Prior authorization — document criteria A–F and procedure code

Prior authorization is required. The request must document that all medical necessity criteria A–F are met and include the procedure code for the planned implantation (e.g., CPT 69930).

Document that criteria A–F (bilateral severe to profound sensorineural hearing loss; limited or no benefit from hearing aids; cognitive ability and willingness to participate in extensive auditory rehabilitation; freedom from middle ear infection and structurally accessible cochlear lumen and freedom from lesions in the auditory nerve/central auditory pathways; no other contraindication for surgery; device used per FDA labeling) are satisfied.
Include the procedure coding (CPT 69930) with the prior authorization submission.

Step Therapy

Conservative therapy — demonstrate limited/no benefit from hearing aids

Show that the member has had limited or no benefit from appropriately fit hearing aids before implanting a cochlear device (this corresponds to criterion B).

Provide clinical evidence demonstrating limited or no benefit from hearing aids prior to the request for cochlear implantation.

Documentation Required

Procedure coding and supporting records — cite CPT 69930 and clinical documentation

Include procedure documentation and supporting clinical records with the request, and reference CPT 69930 (Cochlear device implantation, with or without mastoidectomy) in billing/submission documents.

Attach operative notes, clinic assessments, and other records that demonstrate how the medical necessity criteria are met.
Reference CPT 69930 for the cochlear implantation procedure.

Denial Risk

Denial risk if medical necessity criteria A–F are not met

Requests that do not meet ALL specified medical necessity criteria (A–F) may be denied as not medically necessary.

Ensure every criterion A–F is addressed in the submission to avoid denial.

Clinical Background

Cochlear implants are neuroprosthetic devices indicated for individuals with severe to profound sensorineural hearing loss who receive limited or no benefit from hearing aids. Candidate selection requires intact cochlear anatomy suitable for implantation, absence of contraindicating middle ear infection or neural lesions, and the cognitive ability and willingness to participate in extensive auditory rehabilitation; devices must be used in accordance with FDA labeling.

Key Definitions

Limited or no benefit from hearing aids — definition / key point

DefinitionLimited or no benefit from appropriately fitted hearing aids despite adequate trial

Policy contextListed as criterion B in the initial cochlear implant coverage criteria; must be met for coverage

Provider expectationDocument demonstration of limited or no benefit from hearing aids in prior authorization records

Clinical implicationCandidates who continue to have functional communication with hearing aids are not meeting this criterion

Anatomic/surgical candidacy — freedom from middle ear infection and structurally accessible cochlear lumen

DefinitionFreedom from middle ear infection and an accessible cochlear lumen that is structurally suited to implantation

Policy contextListed as criterion D in the initial cochlear implant coverage criteria; required for coverage

Anatomic requirementsCochlear lumen must be structurally accessible to allow electrode insertion

Infection statusNo active middle ear infection at time of implantation

Neural considerationsFreedom from lesions in the auditory nerve and acoustic areas of the central nervous system per the same criterion

Policy Summary

PayerAmbetter Georgia

PolicyCochlear Implants

Policy CodePolicy WA.CP.MP.502

Change TypeNo material changes

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization documenting that all medical necessity criteria (A–F) are met and include procedure coding (e.g., CPT 69930).

SourceLink

On This Page

Cochlear Implants

Sign up for Ambetter Georgia Policy WA.CP.MP.502 alerts

Cochlear Implant Coverage Criteria

Cochlear Implants

Sign up for Ambetter Georgia Policy WA.CP.MP.502 alerts

Cochlear Implant Coverage Criteria

Procedure and Billing Codes

Prior Authorization, Documentation, and Billing

Clinical Background

Key Definitions