Cochlear Implants Clinical Coverage Criteria
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Defines Fallon Health coverage, prior authorization, and medical necessity determination processes for cochlear implantation and related components across Fallon products; applies to clinicians requesting services for Fallon members.
Effective for dates of service on or after September 1, 2024, Fallon Health will use InterQual® Criteria when making medical necessity determinations for cochlear implants for Community Care members.
New separate sections were added describing Medicare and MassHealth variations and their specific policies and restrictions (including NCD reference and MassHealth exclusions).
Fallon Health requires prior authorization for cochlear implants and that requests must be submitted by the clinician performing the procedure with supporting clinical documentation.
Coverage Criteria for Cochlear Implants
InterQual-based medical necessity
Covered when ALL of the following are met:
InterQual content not reproduced in this policy; reviewers must consult InterQual modules via Fallon Transparency Tool.
Medicare coverage rules
Medicare Advantage members
For Medicare Advantage members enrolled in CMS‑approved Category B IDE trials, Fallon provides coverage for routine care items and CMS‑approved Category B devices as specified under 42 CFR § 422.109(f); Original Medicare reimburses routine costs for qualifying clinical trials per NCD 310.1.
MassHealth coverage rules
MassHealth members
Examples of MassHealth exclusions include age under nine months (rare exceptions considered case‑by‑case), implantation for tinnitus, active middle‑ear or mastoid infection or tympanic membrane perforation at time of PA/procedure, and deafness due to eighth cranial nerve lesions or absence. Replacement of processors and other external components is limited to loss, obsolescence, or beyond repair per MassHealth rules.
Cochlear implantation is not covered for a member who is younger than nine months of age, except in rare, case-by-case situations where urgent clinical circumstances justify earlier implantation (for example, concern for cochlear ossification after meningitis). This age-based exclusion is explicitly listed among the policy exclusions and the MassHealth variation, which notes that exceptions may be considered individually.
Other exclusions that provide coverage context include proposals to treat tinnitus with cochlear implantation, active middle‑ear or mastoid infection or tympanic membrane perforation at the time of the prior authorization request or on the day of the procedure, deafness due to lesions or absence of the eighth cranial nerve, and supplies or accessories not necessary for device function (e.g., convenience or deluxe items).
Under the MassHealth variation, MassHealth does not consider cochlear implantation medically necessary in specified circumstances. One explicit example is when the member is younger than nine months of age; MassHealth states that rare cases requiring coverage before nine months will be evaluated case-by-case (for example, post-meningitis concern for cochlear ossification).
MassHealth also lists other situations where cochlear implantation may not be medically necessary, including use as a treatment for tinnitus, presence of active middle‑ear or mastoid infection or tympanic membrane perforation at the time of prior authorization or on the procedure date, and deafness caused by lesions or absence of the eighth cranial nerve. MassHealth specifies separate rules for replacement and repair of external components that should be followed for MassHealth members.
Procedure and Supply Codes
| 69930 | Cochlear device implantation, with or without mastoidectomy |
| 92601 | Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming |
| 92602 | Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent programming |
| 92603 | Diagnostic analysis of cochlear implant, age 7 years or older; with programming |
| 92604 | Diagnostic analysis of cochlear implant, age 7 years or older; subsequent programming |
| L7510 | Repair of prosthetic device, repair or replace minor parts |
| L7520 | Repair prosthetic device, labor component, per 15 minutes |
| 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, replacement |
| L8621 | Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each |
| L8622 | Alkaline battery for use with cochlear implant device, any size, replacement, each |
What Providers Must Do
Prior authorization required
Prior authorization is required for cochlear implants and must be submitted by the clinician performing the procedure and accompanied by clinical documentation that supports the medical necessity of the procedure. Fallon will use InterQual® Criteria for medical necessity determinations for Community Care members effective 09/01/2024.
- Requests must be submitted by the clinician performing the procedure.
- Requests must include supporting clinical documentation to establish medical necessity.
MassHealth external component replacement rules
For MassHealth members, replacement of an external cochlear implant processor is covered only when the existing processor is obsolete (manufacturer no longer supports repairs), lost (replacement must be same make/model unless obsolete), or beyond repair. Replacement of other external components is covered only when lost or beyond repair.
- Processor replacement allowed if obsolete, lost (replaced by same make/model unless obsolete), or beyond repair.
- Other external component replacements covered only when lost or beyond repair.
Required documentation for medical necessity
Medical necessity determination requires review of the member's medical records, commonly including a recent clinical evaluation with a detailed history and physical examination, laboratory and imaging studies, procedure reports, and reports from other providers participating in care.
- Recent clinical evaluation with detailed history and physical exam.
- Laboratory and imaging studies, procedure reports, and reports from other providers.
Risk of denial if prior authorization not obtained
Failure to obtain prior authorization submitted by the clinician performing the procedure with supporting clinical documentation may result in denial of the request.
- PA requests must be submitted by the clinician performing the procedure and include supporting clinical documentation to avoid denial.
Background
A cochlear implant is an electronic prosthetic device composed of implanted and external components designed to stimulate auditory nerve fibers to provide sound awareness and facilitate communication for individuals with moderate to profound sensorineural hearing loss. Devices require surgical implantation of internal components and use external processors and accessories to deliver sound input and enable programming and rehabilitation.
Definitions
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