ModifiedDHAPolicy 6010.60-M

Cochlear Implantation

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Coverage criteria for cochlear implantation, including adult and pediatric eligibility, device replacement, documentation, rehabilitation, and contraindications.

Policy Summary

PayerDHA

PolicyCochlear Implantation

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateJul 27, 2012

Next Review DateN/A

Key ActionDocument age-appropriate pneumococcal vaccination before implantation.

SourceLink

POLICY UPDATE CHANGES

Unilateral cochlear implantation is covered for adults and children with unilateral hearing loss.

The pediatric bilateral implantation criteria were revised to address slight-to-moderate bilateral sensorineural hearing loss defined as 26-60 decibels.

Coverage criteria were added for children with bilateral severe-to-profound sensorineural hearing loss defined as 61-81 or more decibels.

Coverage criteria were added for children with a history of meningitis resulting in bilateral hearing loss.

Coverage criteria were added for children with evidence of cochlear ossification on CT or MRI.

≤40%Adult limited-benefit threshold

3-6 monthsPediatric hearing-aid trial

26-60 dB

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ModifiedDHAPolicy 6010.60-M

Cochlear Implantation

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Sign up for DHA Policy 6010.60-M alerts

Get alerted when Policy 6010.60-M changes without checking for updates manually.

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Coverage criteria for cochlear implantation, including adult and pediatric eligibility, device replacement, documentation, rehabilitation, and contraindications.

Policy Summary

PayerDHA

PolicyCochlear Implantation

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateJul 27, 2012

Next Review DateN/A

Key ActionDocument age-appropriate pneumococcal vaccination before implantation.

SourceLink

POLICY UPDATE CHANGES

Unilateral cochlear implantation is covered for adults and children with unilateral hearing loss.

The pediatric bilateral implantation criteria were revised to address slight-to-moderate bilateral sensorineural hearing loss defined as 26-60 decibels.

Coverage criteria were added for children with bilateral severe-to-profound sensorineural hearing loss defined as 61-81 or more decibels.

Coverage criteria were added for children with a history of meningitis resulting in bilateral hearing loss.

Coverage criteria were added for children with evidence of cochlear ossification on CT or MRI.

≤40%Adult limited-benefit threshold

3-6 monthsPediatric hearing-aid trial

26-60 dB

Pediatric slight-to-moderate SNHL

61-81+ dBPediatric severe-to-profound SNHL

6-10 sessionsPost-implant rehabilitation

Cochlear Implantation Coverage Criteria

General implantation requirements

Covered when all of the following general criteria are met:

Device, assessment, rehabilitation, and vaccination requirements

Required conditions
- The cochlear implant is an FDA-approved single- or multichannel device used in accordance with FDA-approved labeling for the specific device prescribed.
- The individual has been assessed by an audiologist and an otolaryngologist experienced in cochlear implantation, and the assessments indicate the likelihood of success with the device.
- The individual has the cognitive ability to use auditory clues and is willing to undergo an extended post-implant rehabilitation program.
  The rehabilitation program consists of six to 10 sessions lasting approximately 2.5 hours each.
- The recipient is up-to-date on age-appropriate pneumococcal vaccination before implantation.At least two weeks before implantation
  Vaccination should follow CDC guidance.

Unilateral cochlear implantation

Covered for adults and children with unilateral hearing loss.

Unilateral implantation: The individual has unilateral hearing loss.

Adult bilateral implantation

Covered when all of the following are met:

The individual is 18 years of age or older.
The individual has bilateral, pre- or post-linguistic sensorineural moderate-to-profound hearing impairment.
The individual has received limited benefit from appropriately fitted binaural hearing aids.40% correct or less in the best-aided listening condition on open-set sentence cognition testing
Examples include Central Institute for the Deaf (CID) sentences and Hearing in Noise Test (HINT) sentences.

Pediatric bilateral slight-to-moderate SNHL

Covered when both pediatric criteria are met:

Pediatric bilateral slight-to-moderate SNHL pathway

The child has bilateral slight-to-moderate sensorineural hearing loss.26-60 decibels
Limited benefit from appropriately fitted binaural hearing aids
- Children four years of age or younger: The child has failed to reach developmentally appropriate auditory milestones measured using the Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS), the Meaningful Auditory Integration Scale (MAIS), or the Early Speech Perception test.
- Children four years of age or younger: The child has less than 20% correct on an open-set word-recognition test (Multisyllabic Lexical Neighborhood Test [MLNT]) with appropriate amplification and intensive aural habilitation.

Additional pediatric bilateral implantation categories

Covered when the child meets any one of the following additional categories:

The child has bilateral severe-to-profound sensorineural hearing loss.61-81 or more decibels
The child has a history of meningitis resulting in bilateral hearing loss.
The child has evidence of cochlear ossification on computerized tomography (CT) scan or magnetic resonance imaging (MRI).CT or MRI evidence

Speech processor replacement

Covered when the following replacement criterion is met:

External speech processor replacement: Replacement of the cochlear implant external speech processor device is needed.

Cochlear implantation is contraindicated when preoperative radiographic evidence shows an underdeveloped internal auditory canal or absent cochlear development. It is also contraindicated when a physical condition prevents placement of the electrode array or receiver-stimulator, including cochlear ossification that prevents electrode insertion.

Cochlear implantation is contraindicated in the presence of a middle-ear infection, a cochlear lumen that is structurally unsuited to implantation, or a lesion involving the auditory nerve or the acoustic area of the central nervous system.

The service is not cost-shared when a contraindication to surgery or implantation exists, including poor anesthetic risk, severe mental retardation, severe psychiatric disorders, or organic brain syndrome.

Procedure Codes and Clinical Thresholds

CPT Procedure CodesCPT

69930
90732
92601 - 92604
92626
92627

HCPCS Procedure CodesHCPCS

L8614 - L8629

Adult Open-Set Sentence Cognition

Threshold40% correct or less

Listening conditionBest-aided listening condition

Test typeOpen-set sentence cognition testing

ExamplesCentral Institute for the Deaf (CID) sentences or Hearing in Noise Test (HINT) sentences

Pediatric Slight-to-Moderate SNHL

PopulationChildren with bilateral hearing loss

Hearing-loss type

Documentation and Utilization Requirements

Documentation Required

Pediatric Hearing-Aid Trial Required

For a child without previous hearing-aid experience, document that a three- to six-month hearing-aid trial was undertaken and failed before cochlear implantation is considered.

Documentation Required

Early-Childhood Amplification and Habilitation

For children age four or younger, document limited benefit through failure to reach developmentally appropriate auditory milestones or less than 20% correct on open-set word recognition, in conjunction with appropriate amplification and participation in intensive aural habilitation over three to six months.

Use the Infant-Toddler Meaningful Auditory Integration Scale, Meaningful Auditory Integration Scale, or Early Speech Perception test to document auditory development.
Document the developmental benefit expected from intensive aural habilitation and the child's participation in that program.

Cochlear Implant Overview

A cochlear implant is an electronic device that includes a surgically implanted component and an external component worn or carried by the individual. The external component captures and amplifies sound, while the implanted component stimulates auditory nerve fibers. The device is intended to provide sound awareness, sound identification, and improved communication for individuals with hearing impairment; expected benefit depends on appropriate device selection, audiologic and otolaryngologic assessment, cognitive readiness, and post-implant auditory rehabilitation.

Policy Definitions

Cochlear Implant Device

Device typeElectronic instrument

Implanted componentA component surgically implanted to stimulate auditory nerve fibers

External componentA component worn or carried by the individual to capture and amplify sound

ModelsAvailable in single-channel and multichannel models

Limited Benefit From Amplification in Adults

PopulationAdults receiving appropriately fitted binaural hearing aids

Listening condition

Policy Summary

PayerDHA

PolicyCochlear Implantation

Policy CodePolicy 6010.60-M

Change TypeModified

Effective DateJul 27, 2012

Next Review DateN/A

Key ActionDocument age-appropriate pneumococcal vaccination before implantation.

SourceLink

On This Page

Less than 20% correct on MLNT

Intensive aural habilitation is required over a three- to six-month period.

Children older than four years of age: The child has less than 12% correct on the Phonetically Balanced-Kindergarten (PB-K) test, or less than 30% correct on the HINT for children, open-set MLNT, or Lexical Neighborhood Test (LNT), selected according to the child's cognitive ability and linguistic skills.Less than 12% on PB-K or less than 30% on HINT for children, MLNT, or LNT

Hearing-aid trial when applicable: A child without previous hearing-aid experience has undertaken and failed a hearing-aid trial.Three to six months

Sensorineural hearing loss (SNHL)

Pediatric Severe-to-Profound SNHL

PopulationChildren with bilateral hearing loss

Hearing-loss typeSevere-to-profound sensorineural hearing loss (SNHL)

Range61-81 or more decibels

Pediatric Hearing-Aid Trial

Applicable childA child without previous experience with hearing aids

Required actionUndertake and fail a hearing-aid trial

Trial durationThree to six months

Young-Child Open-Set Word Recognition

PopulationChildren four years of age or younger

TestOpen-set word recognition using the Multisyllabic Lexical Neighborhood Test (MLNT)

Performance thresholdLess than 20% correct

Associated supportAppropriate amplification and intensive aural habilitation over three to six months

Older-Child Speech Perception

PopulationChildren older than four years of age

PB-K thresholdLess than 12% correct on the Phonetically Balanced-Kindergarten Test (PB-K)

Other test thresholdLess than 30% correct on HINT for children, open-set MLNT, or Lexical Neighborhood Test (LNT)

Test selectionSelected according to the child’s cognitive ability and linguistic skills

Prior Authorization

Device and Specialist Assessment

Verify that the prescribed cochlear implant is used in accordance with FDA-approved labeling and obtain assessments from an audiologist and an otolaryngologist experienced in cochlear implantation, including the likelihood of success with the device.

Document the specific FDA-approved device and applicable labeling.
Include both audiologist and experienced otolaryngologist assessments.

Documentation Required

Rehabilitation Readiness

Document the individual's cognitive ability to use auditory clues, willingness to undergo an extended rehabilitation program, and the planned post-implant rehabilitation program required to achieve benefit.

The rehabilitation program consists of six to 10 sessions of approximately 2.5 hours each.
Address development of running-speech understanding, consonant and vowel recognition, and speech-perception testing.

Documentation Required

Audiologic Eligibility Evidence

Submit audiologic evidence supporting eligibility, including the type and severity of hearing loss, appropriately fitted hearing-aid use and benefit testing, and age- and ability-appropriate speech or auditory test results.

For adults with bilateral impairment, document best-aided open-set sentence scores of 40% correct or less when applicable.
For children age four or younger, document auditory milestone results or open-set MLNT word recognition below 20% when applicable.
For children older than four, document PBK below 12% or HINT-for-children, MLNT, or LNT below 30%, as appropriate to cognitive and linguistic skills.

Documentation Required

Pediatric Supporting Records

For pediatric cases, provide records supporting the qualifying pathway, including auditory development and speech-perception results, hearing-loss characteristics, and any relevant meningitis history or imaging findings.

Document bilateral slight-to-moderate SNHL of 26–60 decibels when applicable.
Document bilateral severe-to-profound SNHL of 61–81 or more decibels when applicable.
Include records of meningitis resulting in bilateral hearing loss and CT or MRI evidence of cochlear ossification when applicable.

Prior Authorization

Pneumococcal Vaccination

Confirm and document that the recipient is up-to-date on age-appropriate pneumococcal vaccination in accordance with CDC guidance at least two weeks before implantation.

Record vaccine status and the date vaccination requirements were satisfied.
Resolve any vaccination gap before the planned implant date.

Denial Risk

Failure to Meet Coverage Criteria

Coverage may be denied when required device labeling, specialist assessments, supporting records, or medical-necessity evidence are absent or when the applicable eligibility criteria are not met.

The device must be FDA-approved and used according to its specific labeling.
Audiologist and experienced otolaryngologist assessments must indicate likelihood of success.
Required hearing-aid trial, amplification benefit, auditory or speech testing, rehabilitation readiness, and pediatric records must be documented when applicable.

Denial Risk

Anatomic Contraindication

Do not proceed when preoperative imaging shows an underdeveloped internal auditory canal, absent cochlear development, or another anatomic condition that prevents placement of the electrode array or receiver-stimulator.

Review CT or MRI findings for anatomic feasibility.
Cochlear ossification that prevents electrode insertion is a contraindication.

Denial Risk

Active Disease or Neural Contraindication

Cochlear implantation is contraindicated with a middle-ear infection, a cochlear lumen structurally unsuited to implantation, or a lesion of the auditory nerve or acoustic area of the central nervous system.

Document evaluation for active infection before surgery.
Confirm that cochlear anatomy and the auditory neural pathway are suitable for implantation.

Denial Risk

Medical or Psychiatric Surgical Risk

Do not implant when a contraindication to surgery or implantation creates unacceptable medical or psychiatric risk, including poor anesthetic risk, severe intellectual disability, severe psychiatric disorders, or organic brain syndrome.

Document preoperative medical, anesthetic, psychiatric, and developmental risk assessment.
Address risks that could prevent safe surgery or effective use of the implant.

Best-aided listening condition

TestOpen-set sentence cognition testing

Limited-benefit definition40% correct or less

ExamplesCentral Institute for the Deaf (CID) sentences or Hearing in Noise Test (HINT) sentences

Limited Benefit From Amplification in Children

AgeChildren four years of age or younger

Developmental criterionFailure to reach developmentally appropriate auditory milestones

Milestone measuresInfant-Toddler Meaningful Auditory Integration Scale (IT-MAIS), Meaningful Auditory Integration Scale (MAIS), or Early Speech Perception test

Alternative speech-perception criterionLess than 20% correct on open-set MLNT with appropriate amplification and intensive aural habilitation over three to six months

Pediatric Slight-to-Moderate SNHL

LateralityBilateral

Hearing-loss typeSensorineural hearing loss (SNHL)

Severity classificationSlight-to-moderate

Hearing-loss range26-60 decibels

Pediatric Severe-to-Profound SNHL

LateralityBilateral

Hearing-loss typeSensorineural hearing loss (SNHL)

Severity classificationSevere-to-profound

Hearing-loss range61-81 or more decibels