CurrentColorado Rocky Mountain Health PlansPolicy 2026T0070II

Cochlear Implants — Coverage Criteria and Coding

Medical policy governing indications, coding, benefits, and coverage considerations for cochlear implants (including hybrid devices and external components) for UnitedHealthcare Commercial and Individual Exchange plans; affects providers submitting requests and claims for cochlear implantation and related services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCochlear Implants — Coverage Criteria and Coding

Policy CodePolicy 2026T0070II

Change TypeNo material changes

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain required prior authorization per the member's plan and InterQual clinical criteria before cochlear implantation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

69930, L8614-L8628, V5273procedure and HCPCS codes listed

18+adult age threshold

>=6 mopediatric bilateral threshold

>=9 mopediatric single-sided threshold

ExcludedFM systems

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Coverage and Medical Necessity Criteria

Medical necessity criteria

Covered when meeting InterQual clinical criteria and member-specific benefit plan terms:

Non-hybrid cochlear implantation (Adults): Proven and medically necessary under certain circumstances for bilateral sensorineural hearing loss (SNHL) and for single-sided or asymmetric SNHL in adults ages 18 and older; clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation.age >= 18

Refer to InterQual for specific audiologic thresholds and prior hearing aid trial requirements

Non-hybrid cochlear implantation (Pediatrics): Proven and medically necessary under certain circumstances for bilateral SNHL in children ages 6 months or older and for single-sided or asymmetric SNHL in children ages 9 months or older; clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation (Pediatric).age >= 6 months for bilateral; age >= 9 months for single-sided/asymmetric

Non-hybrid implantation for younger ages is considered experimental/investigational due to lack of FDA approval

Hybrid cochlear implantation (Adults): Hybrid cochlear implantation is proven and medically necessary under certain circumstances for SNHL in adults ages 18 and older; clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation.age >= 18

Refer to InterQual for detailed indications

Coverage for cochlear implantation is contingent on meeting clinical criteria (see InterQual CP: Procedures, Cochlear Implantation) and the member-specific benefit plan. Non-hybrid cochlear implantation is proven and medically necessary under specified circumstances for bilateral and single-sided/asymmetric sensorineural hearing loss (SNHL) when age and other InterQual criteria are met. For adults, hybrid and non-hybrid indications reference InterQual guidance and member benefits. External components (speech processor, microphone, transmitter coil) are considered under the DME benefit while implantable components are considered under the medical-surgical benefit; the member specific benefit plan must be consulted for repair/replacement and coverage limits. Frequency modulated (FM) systems are excluded from coverage and are not considered integral to cochlear implant function.

For pediatric non-hybrid cochlear implantation, the policy specifies age thresholds: children with bilateral SNHL must be at least 6 months of age to meet coverage criteria, and children with single-sided or asymmetric SNHL must be at least 9 months of age. Implantation below these age thresholds is considered experimental or investigational due to lack of FDA approval. Refer to the InterQual Pediatric Cochlear Implantation criteria for the full clinical requirements.

Procedure, HCPCS, and Assistive Device Codes

Covered CPT Codes (reference list)CPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS Codes for external/internal componentsHCPCS

L8614	Cochlear device, includes all internal and external components.
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.

Assistive device codesHCPCS

V5273

Assistive listening device, for use with cochlear implant

Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required

Prior authorization required. Coverage is governed by clinical criteria (InterQual) and the member's benefit terms; prior authorization must be obtained before services are rendered.

InterQual CP: Procedures, Cochlear Implantation (adult and pediatric) applies
Prior authorization required per plan benefits and medical necessity review

Denial Risk

Excluded Accessory

Excluded accessory. Frequency modulated (FM) systems and similar accessories used as extensions of cochlear implants are excluded from coverage and are not considered integral to cochlear implant function.

FM systems do not meet the definition of a covered health care service
Excluded because they do not prevent, diagnose, or treat a sickness or injury and are not integral to cochlear implant function

Clinical Background

Sensorineural hearing loss (SNHL) results from damage to the cochlea or the auditory nerve pathways and is typically permanent. Cochlear implants provide a prosthetic means to bypass damaged hair cells and directly stimulate the auditory nerve for patients with significant SNHL who meet clinical criteria. Cochlear implantation may be medically necessary for bilateral SNHL or for single-sided/asymmetric SNHL in eligible patients per InterQual criteria; external components and follow-up aural rehabilitation are addressed under separate benefit provisions. FM systems are accessory devices that do not meet coverage criteria and are excluded.

Key Terms

Sensorineural Hearing Loss (SNHL)

DefinitionSensorineural Hearing Loss (SNHL): damage to the inner ear (cochlea) or the nerve pathways from the inner ear to the brain; most often not medically or surgically correctable.

Typical permanenceSNHL is the most common type of permanent hearing loss (per ASHA).

Anatomic sites involvedInner ear (cochlea) and auditory nerve pathways to the brain.

Clinical implicationUsually not correctable by medical or surgical means; may be an indication for cochlear implantation when coverage criteria are met.

Source authorityAmerican Speech-Language-Hearing Association (ASHA) referenced in definition.