CurrentColorado Rocky Mountain Health PlansPolicy 2026T0070HH

Cochlear Implants

Defines medical policy for cochlear implantation (non-hybrid and hybrid) across UnitedHealthcare Commercial and Individual Exchange plans (with exceptions), including age-based indications, references to InterQual clinical criteria for medical necessity, benefit considerations, and exclusions (FM systems).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCochlear Implants

Policy CodePolicy 2026T0070HH

Change TypeTemplate Update / Shared policy creation

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must reference and document InterQual® CP: Procedures, Cochlear Implantation (adult) or InterQual® CP: Procedures, Cochlear Implantation (Pediatric) clinical criteria in the medical record to support coverage determinations.

POLICY UPDATE CHANGES

Template Update and created shared policy version to support application to Oxford plan membership; archived previous policy versions 2025T0070GG and ENT 004.38.

Adults & PediatricsCovered Indications Summary

FM systemsExplicitly Excluded Items

InterQualExternal Clinical Criteria Source

Coverage Summary & Scope

Policy 2026T0070HH covers Cochlear Implants. Status: CURRENT. This policy is effective January 1, 2026 and was last reviewed on January 1, 2026. It defines medical policy for cochlear implantation (non-hybrid and hybrid) across UnitedHealthcare Commercial and Individual Exchange plans, references InterQual clinical criteria for medical necessity, includes benefit considerations and coding references, and notes exclusions such as FM systems.

Key Policy Points

Covered Indications SummaryAdults and Pediatrics: non-hybrid cochlear implantation for adults (age ≥18) for bilateral and/or single-sided/asymmetric SNHL; children ≥6 months for bilateral SNHL and ≥9 months for single-sided/asymmetric SNHL; hybrid implants covered for adults (age ≥18)

Explicitly Excluded ItemsFrequency modulated (FM) systems are excluded from coverage; may be denied as not meeting definition of covered health care service

External Clinical Criteria SourceInterQual® CP: Procedures, Cochlear Implantation referenced for adult and pediatric medical necessity criteria

Age-based scope summary (Adults)Adults: non-hybrid and hybrid cochlear implantation covered when InterQual criteria met; adult threshold = 18 years and older

Age-based scope summary (Pediatrics)Pediatrics: non-hybrid cochlear implantation covered for bilateral SNHL ≥6 months and for single-sided/asymmetric SNHL ≥9 months; younger ages are experimental/investigational due to lack of FDA approval

Medical Necessity Criteria

Coverage Determinations for Non-hybrid Cochlear Implantation (Adults)

Covered when ALL of the following are met:

ALL of the following

Indication: bilateral sensorineural hearing loss and/or single-sided or asymmetric sensorineural hearing loss in adults age 18 years or older
Clinical criteria: refer to InterQual® CP: Procedures, Cochlear Implantation for detailed medical necessity criteria

InterQual reference: InterQual® CP: Procedures, Cochlear Implantation

Coverage Determinations for Non-hybrid Cochlear Implantation (Pediatrics)

Covered when ALL of the following are met:

ALL of the following

Indication - bilateral: Indication: bilateral sensorineural hearing loss in children age 6 months or older
Indication - single-sided/asymmetric: Indication: single-sided or asymmetric sensorineural hearing loss in children age 9 months or older
Clinical criteria: refer to InterQual® CP: Procedures, Cochlear Implantation (Pediatric) for detailed medical necessity criteria

InterQual reference: InterQual® CP: Procedures, Cochlear Implantation (Pediatric)

Not Medically Necessary / Experimental or Investigational

ANY of the following

Age - bilateral: Non-hybrid cochlear implantation for bilateral sensorineural hearing loss in children younger than 6 months is experimental or investigational due to lack of FDA approval
Age - single-sided/asymmetric: Non-hybrid cochlear implantation for single-sided or asymmetric sensorineural hearing loss in children younger than 9 months is experimental or investigational due to lack of FDA approval

FDA rationale: Lack of Food and Drug Administration (FDA) approval cited as reason for experimental or investigational determination

Hybrid Cochlear Implantation (Adults)

Covered when ALL of the following are met:

ALL of the following

Indication: sensorineural hearing loss in adults age 18 years or older
Clinical criteria: refer to InterQual® CP: Procedures, Cochlear Implantation for detailed medical necessity criteria

InterQual reference: InterQual® CP: Procedures, Cochlear Implantation

Relevant Codes

Procedure CodesCPT

69930

Cochlear device implantation, with or without mastoidectomy.

Durable Medical Equipment / External Component CodesHCPCS

L8615	Headset/headpiece for use with cochlear implant device, replacement.
L8616	Microphone for use with cochlear implant device, replacement.
L8617	Transmitting coil for use with cochlear implant device, replacement.
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement.
L8619	Cochlear implant, external speech processor and controller, integrated system, replacement.
L8627	Cochlear implant, external speech processor, component, replacement.
L8628	Cochlear implant, external controller component, replacement.
V5273	Assistive listening device, for use with cochlear implant

Provider Actions & Billing Guidance

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must reference and document InterQual® CP: Procedures, Cochlear Implantation (adult) or InterQual® CP: Procedures, Cochlear Implantation (Pediatric) clinical criteria in the medical record to support coverage determinations.

69930

Billing Rule

Benefit delineation for components

External cochlear implant components (speech processor, microphone, transmitter coil) are considered under the DME benefit and implantable components are considered under the medical-surgical benefit; verify member specific benefit plan for DME repair/replacement coverage.

L8615
L8616
L8617
L8618
L8619
L8627
L8628
V5273

Denial Risk

Exclusion for FM systems

Frequency modulated (FM) systems are excluded from coverage and claims for FM systems may be denied as not meeting definition of covered health care service.

Documentation Required

Medical records may be required

Medical records documentation may be required to assess whether the member meets clinical criteria for coverage; lack of documentation does not guarantee coverage.

Background & Definitions

Cochlear implants are surgical devices indicated for sensorineural hearing loss (SNHL). The policy distinguishes non-hybrid cochlear implants (covered for specified adult and pediatric age-based indications with InterQual clinical criteria) from hybrid cochlear implants (covered for certain adults with InterQual criteria). The policy references FDA information for non-hybrid and hybrid devices and directs users to the FDA Premarket Approval/Notification pages for device-specific status. External components (speech processor, microphone, transmitter coil) are treated as DME while implantable components are considered medical-surgical; member-specific benefit documents govern final coverage determinations and benefits for repair/replacement.

Sensorineural Hearing Loss (SNHL): Occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain; most of the time, SNHL cannot be medically or surgically corrected.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCochlear Implants

Policy CodePolicy 2026T0070HH

Change TypeTemplate Update / Shared policy creation

Effective DateJan 1, 2026

Next Review Date

On This Page

OpenPayer

Cochlear Implants

Coverage Summary & Scope

Medical Necessity Criteria

Relevant Codes

Provider Actions & Billing Guidance

Background & Definitions

Revision History