ModifiedCignaPolicy 0190

Cochlear Implants

Policy governing medical necessity and coding for traditional and hybrid cochlear implantation for individuals with sensorineural hearing loss under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyCochlear Implants

Policy CodePolicy 0190

Change TypeAnnual review — multiple revised and removed statements

Effective DateNov 15, 2025

Next Review DateNov 15, 2026

Key ActionObtain prior authorization documenting audiometric thresholds, aided speech scores and results of a hearing-aid trial (or documented waiver) before cochlear implant placement.

SourceLink

POLICY UPDATE CHANGES

Revised policy statements for traditional cochlear implant without an external hearing aid benefit disclaimer.

Revised the policy statement for waiving a hearing aid trial.

Revised the policy statement for a traditional cochlear implant for the treatment of tinnitus.

Removed policy statements for initial and replacement batteries.

Removed policy statements for upgrading of a traditional cochlear implant or component and for auditory brainstem implants.

Title change.

≥70 dBadult PTA threshold

≥90 dBpediatric PTA threshold

3-monthhearing-aid trial

69930,L8614,L8699example codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Cochlear Implantation

Bilateral sensorineural hearing loss (traditional CI)

Covered when ALL of the following are met

Adult criteria (≥18 years): Bilateral, severe-to-profound sensorineural hearing loss determined by pure-tone average (PTA) ≥ 70 dB at 500, 1000, and 2000 Hz AND limited or no benefit from appropriately fitted hearing aids defined as ≤ 60% correct in the best-aided open-set sentence recognition condition.PTA ≥70 dB; aided sentence score ≤60%

Reasonable expectation of significant benefit required.

Pediatric criteria (<18 years): Profound bilateral sensorineural hearing loss with thresholds ≥90 dB at 1000 Hz AND limited or no benefit from a three-month trial of appropriately fitted binaural hearing aids defined by age-specific functional criteria: age ≤5 years — lack of progress in simple auditory skills with appropriate amplification and intensive aural habilitation over 3 months; age >5 years — <20% correct on open-set sentence discrimination testing (age‑appropriate), with the 3‑month trial waived for history of meningitis causing hearing loss or evidence of cochlear ossification on CT/MRI.≥90 dB at 1000 Hz; 3-month hearing-aid trial (or waiver)

Waiver permitted for meningitis or cochlear ossification.

Second (contralateral) traditional CI

Covered when ALL of the following are met for individuals with existing unilateral CI

Adult second-ear criteria (≥18 years): Bilateral severe-to-profound sensorineural hearing loss (PTA ≥70 dB at 500, 1000, 2000 Hz) AND limited or no benefit from an appropriately fitted hearing aid in the contralateral ear defined as ≤60% correct in the best-aided open-set sentence recognition condition.PTA ≥70 dB; aided sentence score ≤60%

Reasonable expectation of significant benefit required.

Pediatric second-ear criteria (<18 years): Profound bilateral sensorineural hearing loss with thresholds ≥90 dB at 1000 Hz AND limited or no benefit from a three-month trial of an appropriately fitted hearing aid in the second ear defined by age-specific criteria (≤5 years: lack of progress in simple auditory skills with appropriate amplification and intensive habilitation over 3 months; >5 years: <20% correct on open-set sentence testing), with waivers for meningitis or cochlear ossification.≥90 dB at 1000 Hz; 3-month trial or waiver

Unilateral sensorineural hearing loss (SSD/AHL) candidacy

Covered when ALL of the following are met

Age and benefit: Age ≥5 years AND obtains limited benefit from an appropriately fitted unilateral hearing aid in the ear to be implanted.age ≥5 years; limited aided benefit per testing

Audiologic configuration: EITHER profound sensorineural hearing loss in one ear with normal or mild hearing in the other (single-sided deafness, SSD) OR profound sensorineural hearing loss in one ear and mild-to-moderately-severe loss in the other with an interaural PTA difference of at least 15 dB (asymmetric hearing loss, AHL).SSD: impaired PTA ≥70 dB with contralateral PTA ≤30 dB; AHL: interaural difference ≥15 dB

Speech test thresholds: For adults: ≤5% correct on CNC monosyllabic word tests in quiet when tested in the ear to be implanted alone; For ages 5–18 years: ≤5% correct on developmentally appropriate aided monosyllabic word lists when tested in the ear to be implanted alone.

Hybrid cochlear implant with external hearing aid

Covered for individuals ≥18 years with residual low-frequency hearing when ALL criteria are met

Hearing profile: Residual low-frequency hearing no poorer than 60 dB HL up to and including 500 Hz AND severe-to-profound mid-to-high-frequency sensorineural hearing loss in the ear to be implanted (average thresholds at 2000, 3000, and 4000 Hz ≥75 dB HL) AND contralateral ear mid-to-high-frequency average ≥60 dB HL.LF ≤60 dB (≤500 Hz); HF average ≥75 dB (2000–4000 Hz); contralateral ≥60 dB

Speech scores and benefit: Preoperative aided CNC word recognition in the ear to be implanted between 10% and 60% AND contralateral ear CNC score equal to or better than the implanted ear but no greater than 80% correct.CNC 10–60% (implanted ear); contralateral ≤80%

Limited benefit from conventional hearing aids required.

Exclusions: No lesions of the acoustic nerve or central auditory pathway; no active middle ear disease; presence of cochlear development; duration of severe-to-profound hearing loss less than 30 years.

Replacement of existing traditional cochlear implant

Considered medically necessary when EITHER of the following is met

Replacement criteria: Currently used component is nonfunctional and cannot be repaired with no evidence of abuse or neglect OR the currently used component renders the implant recipient unable to adequately and/or safely perform age‑appropriate activities of daily living.

Replacement for device damage from abuse/neglect is not medically necessary.

Candidate clinical criteria (general / SSD/AHL)

Covered when ALL device- and age-specific FDA and clinical criteria are met

General candidate requirements: Candidate demonstrates moderate-to-profound bilateral sensorineural hearing loss (or for SSD/AHL, profound loss in one ear with preserved contralateral hearing), confirmed by audiometric testing and speech-recognition scores; limited or no benefit from appropriately fitted hearing aids must be documented unless a waiver is justified (e.g., cochlear ossification or meningitis).see device- and age-specific thresholds (PTA, speech scores)

Verify device-specific FDA indications and age limits before authorization.

Pediatric specifics: For children, limited benefit from binaural hearing aids is age‑dependent: age ≤5 years — lack of progress in simple auditory skills after 3 months of appropriate amplification with intensive aural habilitation; age >5 years — <20% correct on open‑set sentence discrimination (age-appropriate). Behavioral thresholds (PTA/SRT) may be ≥90 dB for candidacy; objective testing (OAE, ABR, ASSR) may substitute when behavioral testing is unreliable.age-based definitions; pediatric PTA thresholds may be ≥90 dB

Documentation of rehabilitation potential and willingness is required.

Hybrid cochlear implant candidacy (FDA-specified criteria)

Covered when ALL of the following FDA criteria are met:

Hybrid candidacy (FDA): Patient is an adult (≥18 years) with residual low-frequency hearing (thresholds no poorer than 60–65 dB HL up to and including 500 Hz) AND severe-to-profound sensorineural hearing loss in mid-to-high frequencies (thresholds averaging ≥70–75 dB HL at 2000 Hz and above) AND limited benefit from conventional hearing aids AND a CNC word recognition score of ≤60% in the ear to be implanted.LF ≤60–65 dB up to 500 Hz; HF average ≥70–75 dB (≥2000 Hz); CNC ≤60%

Per FDA PMA device labeling; verify device-specific indications and labeling for age and score limits.

Expected outcomes and risks

Considered medically beneficial when expected benefits outweigh risks:

Potential benefits: Significant improvements in speech perception (CNC and sentence tests) in quiet and noise, improved patient satisfaction and quality of life, and improved sound localization in some studies.

Reported across case series and longitudinal observational studies and supportive systematic reviews.

Known risks: Risk of loss of residual low-frequency hearing (reported variably across studies, including substantial proportions in some series), surgical and anesthesia risks, device-related complications (including device failure requiring revision), and potential contraindications for some medical procedures (e.g., MRI considerations).

Providers must counsel patients on the potential for irreversible loss of residual hearing and device-related adverse events.

Hybrid (short-electrode) cochlear implant clinical inclusion criteria (as reported in trials)

Common audiometric and clinical inclusion criteria used in pivotal/clinical studies for hybrid devices — covered when ALL of the following are met in trial protocols

Hybrid CI trial inclusion: Adult participants (typically ≥18 years) with severe-to-profound high-frequency sensorineural hearing loss (>75 dB HL averaged over high frequencies or thresholds >1500 Hz poorer than specified limits) AND low-frequency thresholds (125–500 Hz) ≤60 dB HL (3-frequency LF PTA) AND preoperative aided CNC monosyllabic word scores in the ear to be implanted between approximately 10% and 60% with contralateral ear aided word recognition similar or better but not exceeding ~80%; prior hearing aid trial (e.g., minimum six weeks to three months depending on study) and exclusion of duration of hearing loss >30 years in many trials.LF PTA ≤60 dB (125–500 Hz); HF average >75 dB; CNC 10–60% (implanted ear); contralateral ≤80%

Derived from Roland, Gantz, Lenarz and pivotal hybrid study protocols; soft-surgery techniques and monitoring of LF preservation commonly used.

Outcomes and risk profile

Reported outcome expectations and adverse event rates from key studies

Expected benefits and risks: Clinical studies report significant improvements in CNC word scores and sentence tests in the implanted ear and combined listening conditions at 3–6 months, maintained up to multi‑year follow-up; however, 16%–34% (and in some reports up to ~34%) of subjects may not maintain functional acoustic hearing long-term, some experience profound loss of low-frequency hearing, and a minority required explantation and reimplantation with standard CIs.as reported in trials

Adverse event rates include loss of residual hearing, device circuit failures, increased or new tinnitus, and explantation in a subset of participants.

Cochlear implantation performed solely to treat tinnitus in an individual who does not also have severe or profound sensorineural hearing loss is not considered medically necessary. While some patients with hearing loss who receive implants report incidental tinnitus reduction, systematic reviews and studies are heterogeneous and do not provide sufficient evidence to support CI as a primary treatment for tinnitus alone.

Device and product names included in this policy are informational only. Inclusion of specific devices or FDA identifiers does not guarantee coverage, endorse particular manufacturers, or represent an exhaustive list of clinically available products.

Replacement of an implant component that is the result of lack of reasonable care, abuse, or neglect (for example, damage consistent with misuse) is considered not medically necessary and is not covered. Medically necessary replacement requires that the component be nonfunctional and irreparable without evidence of device neglect.

A traditional cochlear implant should not be used solely to treat tinnitus in patients who do not meet the standard severity indications for implantation. Evidence is insufficient to support implantation for tinnitus alone in individuals without concomitant severe or profound sensorineural hearing loss that would otherwise warrant cochlear implantation.

Clinical trials of hybrid and short-electrode cochlear implants commonly applied timing and duration limits for eligibility: many studies required a minimum prior hearing-aid trial (examples include at least six weeks of high-power hearing-aid use) and excluded patients with very long-duration losses (e.g., duration of severe-to-profound loss > 30 years) or very recent onset (< 2 years) in some protocols. Age restrictions used in trials frequently limited enrollment to adults (≥18 years) for hybrid devices.

Policy revisions removed prior statements addressing upgrading of a traditional cochlear implant or component and statements regarding auditory brainstem implants; the policy no longer contains those operational statements and providers should refer to the full policy for current guidance.

Traditional cochlear implantation performed for the purpose of treating tinnitus in the absence of a qualifying severe or profound sensorineural hearing loss is considered not medically necessary. Incidental tinnitus improvement after CI in individuals implanted for hearing indications has been reported, but this does not constitute support for implantation where hearing criteria are not met.

Available evidence includes systematic reviews, randomized and nonrandomized trials, and case series, many of which are small and heterogeneous in design. While these data generally support improved speech perception, localization, and quality-of-life outcomes with cochlear implantation, limitations in study size, variable outcome measures, and heterogeneity across implants and patient populations are consistently noted.

When replacement is indicated for a bilateral implant patient, replacement of the contralateral implant is not considered medically necessary unless that contralateral device is also malfunctioning or otherwise renders the recipient unable to adequately and safely perform age-appropriate activities of daily living and cannot be repaired.

Clinical reports of hybrid implant experience describe device removals and revisions in some subjects due to dissatisfaction or progressive loss of residual acoustic (low-frequency) hearing. These occurrences were documented in pivotal series and highlight the potential for loss of functional acoustic hearing after implantation.

Statements regarding coverage for initial and replacement batteries were removed from the policy during the most recent revisions. The policy no longer provides guidance on battery coverage; consult the full policy or benefit plan documents for current billing and coverage rules.

Coding and Clinical Thresholds

Considered Medically Necessary when criteria metmixedCovered

69930	Cochlear device implantation, with or without mastoidectomy
L8614	Cochlear device, includes all internal and external components
L8699	Prosthetic implant, not otherwise specified

FDA product codes / example device identifiersmixed

MCM	FDA product code for cochlear implant systems (example)

Example device identifiers (informational)mixed

P960058	Clarion Multi-Strategy Cochlear Implant (Advanced Bionics) - FDA identifier (example)
P970051	Nucleus 24 Cochlear Implant System (Cochlear Americas) - FDA identifier (example)
P000025	MED-EL Cochlear Implant System (MED-EL Corporation) - FDA identifier (example)

Example device decision dates (informational)mixed

S205	Nucleus 24 Cochlear Implant System supplement/decision (example)
S104	MED-EL Cochlear Implant System supplement/decision (example)

Notemixed

Device or product names provided for example purposes only; inclusion does not indicate endorsement; list not exhaustive.

FDA/Product Codesmixed

PGQ	FDA product code for cochlear implants with combined electrical stimulation and acoustic amplification
P130016	Nucleus Hybrid L24 Cochlear Implant System - FDA identifier (example)
P000025	Med-El Cochlear Implant System - FDA identifier (example)

Device characteristics (informational)mixed

Hybrid implants are Class III PMA devices for adults ≥18 with residual low-frequency hearing (thresholds no poorer than 60-65 dB HL up to 500 Hz) and require CNC word recognition ≤60% in the ear to be implanted.

Medicare/NCD referencesmixed

No codes listed

Key Medicare reference (informational)mixed

50.3	National Coverage Determination (NCD) Cochlear Implantation
9/26/2022	NCD revision effective date (example)

inv-26: Audiometric thresholds and speech scores — key numeric thresholds used across policy

Adult PTA screeningPure-tone average (500,1000,2000 Hz) ≥ 70 dB HL for adults (screening threshold for severe-to-profound loss)

Pediatric profound thresholdThresholds ≥ 90 dB HL at 1000 Hz for children when defining profound bilateral loss

Aided sentence recognition (adults)Limited or no benefit defined as ≤ 60% correct in best-aided open-set sentence recognition

CNC range for hybrid candidacyPreoperative aided CNC word recognition in ear to be implanted between 10% and 60% (hybrid-specific studies/labels)

Contralateral ear CNC limit (hybrid)Contralateral ear CNC score equal to or better than implanted ear but no more than 80% correct

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for cochlear device implantation and associated device codes. Providers should check the full policy and prior authorization portal for current required codes and submission instructions before scheduling procedures.

Affected example codes: 69930, L8614, L8699 (confirm current code list prior to submission).
Verify payer‑specific prior authorization requirements and submit required clinical documentation with the request.

Documentation Required

Preoperative Evaluation and Rehabilitation Plan

Document preoperative evaluation by both an audiologist and an otolaryngologist experienced in cochlear implantation, and include a documented post‑operative rehabilitation plan. The patient and/or family should be willing and able to participate in aural rehabilitation; document cognitive or psychological capacity to participate.

Include statement that reasonable expectation of significant benefit exists and note absence of medical or surgical contraindications (e.g., active middle ear disease, terminal illness).

Background and Clinical Context

Sensorineural hearing loss results from dysfunction of cochlear hair cells or the auditory nerve pathways and can be congenital or acquired. Traditional cochlear implants electrically stimulate the auditory nerve to provide access to high-frequency sound for individuals with severe-to-profound loss, while hybrid devices combine a short intracochlear electrode for electrical stimulation with an external hearing aid to preserve and use residual low-frequency acoustic hearing. Preoperative candidacy assessment relies on audiometric thresholds, speech-recognition testing, and evaluation of rehabilitation potential.

Definitions and Key Terms

inv-54: Pure-tone average (PTA) definition

Definition of PTAPure-tone average (PTA) is a summary audiogram measure computed from thresholds at specified frequencies (commonly 500, 1000, and 2000 Hz or the four-frequency average including 4000 Hz)

Purpose of PTAUsed to classify hearing severity and guide candidacy screening for cochlear implantation

Common frequency setsCommon PTA formulations: speech-frequency average (500, 1000, 2000 Hz) and four-frequency average (500, 1000, 2000, 4000 Hz)

inv-55: Profound hearing loss definition — PTA ≥90 dB HL

Profound hearing loss thresholdProfound hearing loss is defined as PTA ≥ 90 dB HL at 500, 1000, 2000 and 4000 Hz

Use in pediatric criteriaThis PTA definition is applied when defining profound bilateral sensorineural hearing loss in children for CI candidacy

Policy Revision History

2025-11-15Annual reviewLatest

Title change; removed policy statements for initial and replacement batteries; removed policy statements for upgrading of a traditional cochlear implant or component and for auditory brainstem implants; revised policy statements for traditional cochlear implant without an external hearing aid benefit disclaimer.

2024-11-15Annual review

Revised the policy statement for waiving a hearing aid trial and revised the policy statement for traditional cochlear implant for the treatment of tinnitus.

Policy Summary

PayerCigna

PolicyCochlear Implants

Policy CodePolicy 0190

Change TypeAnnual review — multiple revised and removed statements

Effective DateNov 15, 2025

Next Review DateNov 15, 2026

Key ActionObtain prior authorization documenting audiometric thresholds, aided speech scores and results of a hearing-aid trial (or documented waiver) before cochlear implant placement.

SourceLink

On This Page

CNC/monosyllabic ≤5%

SSD/AHL specifics: For SSD/AHL, FDA approvals require profound sensorineural hearing loss in one ear, limited benefit from conventional amplification, and preserved contralateral hearing; some device approvals specify minimum age (often ≥5 years) and/or an interaural PTA difference of ≥15 dB for AHL.SSD: impaired PTA ≥70 dB with contralateral PTA ≤30 dB; AHL: interaural difference ≥15 dB

Clinical evidence supports improvements in localization, speech-in-noise, and tinnitus reduction versus CROS/BAHA in selected patients.

inv-27: Pure-Tone Average (PTA) thresholds — adult and pediatric screening thresholds

Adult PTA thresholdPure-tone average (PTA) ≥ 70 dB HL (500, 1000, 2000 Hz) used for adult candidate screening

Pediatric PTA/profoundChildren: profound bilateral loss defined by thresholds ≥ 90 dB HL at 1000 Hz (behavioral/age-specific criteria)

SSD/AHL PTA criteriaSingle-sided deafness: impaired ear PTA ≥ 70 dB HL with contralateral ear PTA ≤ 30 dB HL; AHL: better ear PTA between 30 and 55-60 dB HL with significant interaural difference

inv-28: Low-frequency hearing threshold for hybrid candidacy — no poorer than 60-65 dB HL up to and including 500 Hz

Low-frequency threshold limitResidual low-frequency hearing no poorer than 60-65 dB HL up to and including 500 Hz for hybrid candidacy

Study inclusion LF limitClinical trials commonly required low-frequency thresholds ≤ 60 dB HL at 125–500 Hz (LF PTA) for inclusion

Preservation focusHybrid device labeling and trials emphasize preoperative LF thresholds to support acoustic amplification post-implantation

inv-29: High-frequency hearing threshold for hybrid candidacy — thresholds averaging ≥70-75 dB HL at 2000 Hz and above

High-frequency severity requirementSevere-to-profound mid-to-high-frequency loss with thresholds averaging ≥ 70–75 dB HL at 2000 Hz and above for hybrid candidacy

Trial/device averagesTrials and device labels specify 2000, 3000, 4000 Hz averages (e.g., ≥75 dB HL) to characterize high-frequency loss

Contralateral mid-high requirementSome protocols require contralateral ear mid-high-frequency average ≥ 60 dB HL for hybrid candidacy

inv-30: CNC word recognition score requirement — CNC ≤ 60% in the ear to be implanted

CNC implanted-ear requirementCNC word recognition score of ≤ 60% in the ear to be implanted is required for FDA hybrid device candidacy

CNC range in studiesHybrid trials enrolled subjects with aided CNC scores between approximately 10% and 60% in the ear to be implanted

Contralateral CNC constraintsContralateral ear CNC often required to be equal to or better than implanted ear but ≤ 80% in labeling/studies

inv-31: LF PTA preservation threshold — examples: 3-frequency LF PTA ≤ 60 dB HL for candidacy; preservation defined as ≤10 dB change at 125–500 Hz at 1 year

LF PTA candidacy exampleThree-frequency low-frequency PTA (125, 250, 500 Hz) ≤ 60 dB HL used in trials as an example candidacy threshold

Preservation definition at 1 yearPreservation of LF hearing defined in some studies as ≤ 10 dB change at 125–500 Hz at one year post-implantation (Lenarz et al.)

Reported preservation ratesStudies report variable preservation (e.g., 61% preserved ≤10 dB change at 1 year in Lenarz; Gantz reported 83–92% maintaining functional LF hearing by device)

If meningitis or cochlear ossification is present, document rationale for expedited implantation and any waiver of typical hearing‑aid trial requirements.

Prior Authorization

Hybrid Device Candidacy — Authorization Documentation

For hybrid device candidates, prior authorization should document that adult candidates meet FDA‑specified hybrid device criteria, including preserved low‑frequency hearing and the device‑specific CNC/audiometric thresholds. Include preoperative aided CNC scores and low‑frequency thresholds (up to 500 Hz).

Document low‑frequency thresholds no poorer than ~60–65 dB HL up to and including 500 Hz.
Document mid‑to‑high‑frequency loss consistent with device labeling (e.g., 2000–4000 Hz averages ≥70–75 dB HL) and preoperative aided CNC word recognition in the ear to be implanted between ~10%–60% (device‑specific limits).
Confirm contralateral ear CNC and thresholds meet device labeling (often ≤80% CNC in contralateral ear).

Documentation Required

Required Audiometric and Hearing‑Aid Trial Documentation

Document audiometric test results and hearing‑aid trial details in all authorization requests. Include pure‑tone thresholds across 125–8000 Hz (air and bone conduction), pure‑tone averages (PTA), and aided speech perception/open‑set sentence testing results (best‑aided condition).

Include documentation of aided open‑set sentence scores (best‑aided listening condition) and CNC/monosyllabic word scores for adults when applicable.
For children, include age‑appropriate aided speech tests and developmental progress notes; for infants use objective measures (ABR, OAEs) when behavioral testing is not possible.

Documentation Required

Hearing‑Aid Trial Requirement

A documented hearing‑aid trial is generally required prior to cochlear implantation unless device labeling or clinical circumstances allow a waiver (e.g., cochlear ossification or meningitis). For children, a typical binaural hearing‑aid trial is three months unless waived per policy.

Child waiver conditions: history of meningitis causing hearing loss or evidence of cochlear ossification on CT/MRI.
For adults, document that appropriately fitted hearing aids were used and provide aided speech recognition scores showing limited or no benefit.

Step Therapy

Step‑Therapy and Conservative‑Management Considerations

When applicable, document that less invasive or rerouting options were tried and failed (e.g., appropriately fitted hearing aids, CROS, BAHA). Include duration, device type, fitting details, and objective outcome measures demonstrating insufficient benefit.

If prior use of CROS or BAHA devices occurred, provide trial duration and functional outcome measures.
If step therapy is not clinically appropriate, document rationale and supporting clinical findings.

Step Therapy

Restorative vs. Rerouting Device Step‑Therapy

No explicit step‑therapy sequence is required between restorative implants (CIs) and rerouting devices (CROS/BAHA); evidence is limited. When choosing between device classes, document clinical rationale and any comparative trials or failures of rerouting devices.

If CI is selected over a rerouting device without a prior trial of the latter, document why rerouting was unsuitable or would not provide adequate benefit (e.g., localization, speech‑in‑noise needs).

Denial Risk

Replacement and Device‑Related Denial Risks

Replacement or revision requests must document device failure or functional impairment. Denials may occur if the current component is repairable, device abuse/neglect is evident, or the reason for replacement is not a covered medical need.

Include manufacturer service reports, imaging, and clinical assessment showing non-repairable failure or that the device impairs activities of daily living.
Do not submit replacement requests for elective upgrades or non‑medical reasons without documented medical necessity.

Note

Confirm Documentation After Policy Revisions

Confirm required documentation and applicable criteria after policy revisions. Some items (e.g., batteries, component upgrades, auditory brainstem implants) may have been removed or changed — verify current coverage statements and submission requirements before proceeding.

Review the policy change log and the payer’s prior authorization website for updates effective 11/15/2025.
If prior authorization was obtained under a prior policy, confirm whether re‑submission or supplemental documentation is needed under the revised policy.

Relation to classificationsProfound category sits above severe (71–90 dB HL) in standard hearing loss severity classifications

inv-56: Limited or no benefit from hearing aids — policy-level definition for adults/children

Adult policy-level definitionFor adults: limited or no benefit from appropriately fitted hearing aids is defined as ≤ 60% correct in best-aided open-set sentence recognition

Pediatric definition and trialFor children: limited benefit defined by age-specific criteria after a three-month trial (≤5 years: lack of progress in simple auditory skills; >5 years: <20% correct on open-set sentence testing)

Waiver conditionsHearing-aid trial may be waived for conditions such as recent meningitis or cochlear ossification documented on imaging

inv-57: Single-Sided Deafness (SSD) definition — PTA criteria

SSD PTA definitionSingle-Sided Deafness (SSD) defined as unilateral severe-to-profound deafness with impaired ear PTA ≥ 70 dB HL and a better ear PTA ≤ 30 dB HL

Clinical contextSSD includes individuals with normal or near-normal audiometric function in the contralateral ear who receive little or no benefit from amplification in the impaired ear

Common etiologiesCauses include sudden idiopathic sensorineural loss, vestibular schwannoma, meningitis, trauma, Ménière's disease and infections

inv-58: Asymmetric Hearing Loss (AHL) definition

AHL definitionAsymmetric Hearing Loss (AHL): better ear PTA between 30 and 55-60 dB HL with a significant interaural PTA difference (often ≥15 dB)

Functional implicationBetter ear is not normal but can be aided; candidacy assessments consider interaural differences and aided benefit

Relation to SSDAHL encompasses cases distinct from SSD where contralateral hearing is impaired but potentially aided

inv-59: Hybrid cochlear implant definition

Hybrid CI conceptA hybrid cochlear implant combines a shorter intracochlear electrode array providing electrical stimulation for high frequencies with an external hearing aid providing acoustic amplification for low frequencies

Intended populationDesigned for adults with residual low-frequency hearing who have severe-to-profound high-frequency loss

Surgical/technical featuresUses a shorter/softer electrode inserted into the basal cochlea to preserve apical (low-frequency) function while electrically stimulating high frequencies

inv-60: CNC word lists — definition and use

CNC descriptionConsonant-Nucleus-Consonant (CNC) word lists are open-set monosyllabic word recognition tests (10 lists of 50 words) used to assess speech perception in quiet; scores reported as percent correct

Role in hybrid testingConsidered the gold standard for testing and management of hybrid cochlear implant users

Scoring and useUsed preoperatively and postoperatively to quantify aided and implant-ear speech perception (reported as percentage correct)

inv-61: Hybrid cochlear implant / short electrode — definition

Short-electrode/combined EASHybrid cochlear implant / short-electrode devices are designed to preserve low-frequency acoustic hearing while providing electrical stimulation for high frequencies (examples: Nucleus Hybrid S8, S12, L24)

ObjectivePrimary goal is to improve speech recognition in ski-slope/high-frequency loss while attempting to retain residual low-frequency hearing via acoustic amplification

Device featuresShorter intracochlear electrode arrays (shallower insertion depth) and an external processor with acoustic component characterize these systems

inv-62: Functional low-frequency hearing — definition (LF PTA thresholds)

Functional LF hearing definitionFunctional low-frequency hearing commonly defined as LF PTA (e.g., 125–500 Hz) ≤ 60 dB HL in studies and candidacy criteria

Measurement frequenciesResidual hearing often measured using three-frequency (125, 250, 500 Hz) LF PTA or five-frequency LF PTA (125–1000 Hz) in trials

Preservation benchmarksStudies report preservation benchmarks such as ≤10 dB change at LF frequencies at one year post-implant to indicate preserved function

inv-63: Single-sided deafness / asymmetric hearing loss — referenced clinical condition in cited studies

Clinical condition referencedSingle-sided deafness (SSD) and asymmetric hearing loss (AHL) are discussed across multiple cited studies assessing cochlear implantation benefit for speech perception, localization, and tinnitus reduction

Evidence baseMultiple studies and systematic reviews cited in the references evaluate outcomes of CI for SSD/AHL (speech-in-noise, localization, quality of life)

Use in criteriaSSD/AHL definitions and study findings inform candidate criteria (e.g., age limits, PTA thresholds, speech-score cutoffs)

inv-64: Hybrid cochlear implant — short-electrode or combined EAS approach (definition overlap)

Overlap in definitionsHybrid cochlear implant describes both short-electrode designs and combined electric-acoustic stimulation (EAS) approaches—terms used interchangeably in trials and device labeling

Examples providedTrials and device labels cite specific hybrid devices (e.g., Nucleus Hybrid L24, S8, S12) as examples of short-electrode/EAS systems

Clinical implicationsTerminology overlap emphasizes that hybrid/short-electrode systems aim to balance speech-recognition benefit with preservation of residual LF hearing