CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Auditory Brainstem Implant

Coverage rules for unilateral auditory brainstem implants (ABI) primarily for patients with neurofibromatosis type 2; describes coverage stance, age limits, coding, and exclusions for other indications and device types for BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAuditory Brainstem Implant

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 3, 2010

Next Review DateMar 20, 2024

Key ActionVerify member benefits and eligibility against the benefit booklet or subscriber agreement before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12minimum patient age for covered ABI

Q85.02ICD-10 for covered indication

92640, S2235covered procedure codes listed

Not coveredbilateral ABI

ExcludedPABI

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Medically necessary coverage (NF2)

Covered when ALL of the following are met

Coverage - NF2 unilateral ABI: Patient has neurofibromatosis type 2 (ICD-10 Q85.02); patient is 12 years of age or older; patient is rendered deaf due to bilateral resection of neurofibromas of the auditory nerve; unilateral auditory brainstem implant using surface electrodes on the cochlear nuclei is performed.age >= 12 years

Applies to Medicare Advantage and Commercial Products

Not medically necessary / Not covered

Not covered / Not medically necessary when ANY of the following apply

Excluded indications and device types: Auditory brainstem implant for indications other than neurofibromatosis type 2; bilateral use of an auditory brainstem implant; penetrating electrode auditory brainstem implant (PABI).

Evidence insufficient to determine effects on health outcomes

An auditory brainstem implant is not covered or is considered not medically necessary when performed for indications other than neurofibromatosis type 2. The policy explicitly excludes use of an ABI for all other conditions including non‑neurofibromatosis type 2 indications, as evidence is insufficient to determine the effects of the technology on health outcomes. Additionally, the policy excludes bilateral use of an auditory brainstem implant and penetrating electrode auditory brainstem implants (PABI) from coverage.

For Commercial Products the policy states that unilateral ABIs using surface electrodes are medically necessary only for patients meeting the NF2 criteria. The policy further clarifies that, for Commercial Products, ABI for all non‑NF2 conditions, bilateral ABI, and PABI are considered not medically necessary because the available evidence is insufficient to support their use.

Coding and Diagnosis

Covered procedure codesCPT | HCPCSCovered

92640	Diagnosis analysis with programming of auditory brainstem implant, per hour
S2235	Implantation of auditory brainstem implant

Covered diagnosis codeICD-10Covered

Q85.02

Neurofibromatosis, type 2

inv-07: Minimum Age — age requirement for coverage

Minimum age for coverage12 years (patients must be 12 years of age or older)

Age applicabilityApplies to both Medicare Advantage and Commercial Products

Covered indication age requirementAge requirement applies when patient has neurofibromatosis type 2 (ICD-10 Q85.02) and is rendered deaf after bilateral auditory nerve tumor resection

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when applicable under the member's benefit plan. Verify member benefits and obtain prior authorization through the payer's established prior authorization process before scheduling services when the member's contract requires prior authorization.

Verify benefits and prior authorization requirements with Blue Cross & Blue Shield of Rhode Island prior to service.
Use the provider call center or payer portal to confirm authorization requirements for the specific member and group/contract.

Denial Risk

Denial Triggers — Coverage Limitations

Benefits and coverage may vary between groups/contracts. Procedures not meeting the policy’s coverage criteria — including indications other than neurofibromatosis type 2, bilateral auditory brainstem implant (ABI), or penetrating electrode auditory brainstem implant (PABI) — are considered not covered or not medically necessary and may be denied.

Not covered / not medically necessary: ABI for indications other than NF2.
Not covered / not medically necessary: Bilateral use of an auditory brainstem implant.
Not covered / not medically necessary: Penetrating electrode auditory brainstem implant (PABI).

Step Therapy

No step therapy requirements specified for this technology. Standard benefit verification is required to determine any plan-specific utilization management applicable to the member.

Step therapy: none specified for auditory brainstem implant.
Always verify member benefits for any plan-specific utilization management or prior authorization rules.

Background

An auditory brainstem implant (ABI) is a device composed of an implanted electrode array placed on the surface of the cochlear nucleus with an external speech processor and implanted receiver/stimulator. It bypasses the inner ear and auditory nerve to provide auditory stimulation and is intended to restore some hearing in patients—primarily those with neurofibromatosis type 2 who become deaf after bilateral resection of vestibular schwannomas. Placement requires visualization of brainstem landmarks and may be limited by large or distorting tumors; functional outcomes are generally modest but can be meaningful for patients without other options.

Definitions

inv-13: Auditory Brainstem Implant (ABI) — device definition and components

Device definitionAn auditory brainstem implant (ABI) consists of an external speech processor and an implanted receiver/stimulator attached to an electrode array placed on the surface of the cochlear nucleus to bypass the inner ear and auditory nerve and provide auditory stimulation.

Primary componentsExternal speech processor; implanted receiver/stimulator in the temporal bone; electrode array on the cochlear nucleus (brainstem).

FunctionThe external processor sends electrical signals to the implanted receiver/stimulator, which delivers stimulation to multiple sites on the cochlear nucleus that are processed by the brain to produce hearing sensations.

inv-14: Penetrating Electrode ABI (PABI) — PABI definition and exclusion rationale

PABI definitionPenetrating Electrode Auditory Brainstem Implant (PABI) refers to an ABI that uses penetrating electrodes rather than surface electrode arrays.

Policy stancePABI is specifically identified as not covered / not medically necessary due to insufficient evidence to determine effects on health outcomes.

Exclusion rationaleThe evidence is insufficient to determine the effects of penetrating electrode ABIs on health outcomes, so PABI is excluded alongside bilateral use and non-NF2 indications.