CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Auditory Brainstem Implant

Defines coverage determination for auditory brainstem implant (ABI) for Medicare Advantage and Commercial products, specifying covered and not-covered indications, age criteria, diagnosis code, and associated procedure codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Auditory Brainstem Implant

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 2, 2010

Next Review Date

Key ActionProvider must document ICD-10-CM Q85.02 (neurofibromatosis type 2), patient age (>=12 years), and that deafness is due to bilateral resection of neurofibromas of the auditory nerve to support coverage.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or criteria.

1Covered Indication (NF2)

3Not Covered / Not Medically Necessary Scenarios

2CPT/HCPCS codes listed

Coverage Summary

Scope: This policy defines coverage for the Auditory Brainstem Implant (ABI) for Medicare Advantage and Commercial products, specifying covered and not-covered indications, age criteria, diagnosis code, and related procedure codes.

High-level covered vs not-covered: Covered (or medically necessary) when ALL high-level criteria are met: diagnosis of NF2 (ICD-10 Q85.02), age ≥ 12 years, deafness due to bilateral resection of neurofibromas of the auditory nerve, and unilateral ABI using surface electrodes on the cochlear nuclei. Not covered / not medically necessary for: ABI for non-NF2 indications, bilateral ABI use, and penetrating electrode ABI (PABI).