CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Cochlear Implant

Clinical review criteria governing medical necessity determinations for cochlear implant devices (including hybrid cochlear implants) for Kaiser Foundation Health Plan of Washington members; distinguishes Medicare and non-Medicare guidance and references MCG guidelines for non-Medicare determinations.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Cochlear Implant

Policy CodePolicy N/A

Change TypeHybrid not coveredhistorical removals

Effective DateFeb 6, 2025

Next Review Date

Key ActionWhen requesting cochlear implantation for non-Medicare members, submit the most recent audiogram/hearing test and most recent clinical notes from the requesting provider to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Removed MTAC Reviews on Bilateral Cochlear Implants from 2004 and 2006 as it is no longer applicable and covered using KP/MCG Guidelines.

Hybrid cochlear implant criteria: determined to be not covered due to insufficient evidence to support effectiveness/safety compared with standard cochlear implants.

Various historical updates noted (adoption of KP-0177 MCG guidelines for cochlear implant determinations; additions for unilateral sensorineural hearing loss, single-sided deafness, replacement exclusion language, and removal of non-applicable CPT codes over prior years).

1Primary covered CPT code listed

4HCPCS device/component codes listed

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Coverage Summary

Scope: Clinical review criteria governing medical necessity determinations for cochlear implant devices (including hybrid cochlear implants) for Kaiser Foundation Health Plan of Washington members. Subject: Cochlear Implant (including Hybrid Cochlear Implant). Coverage stance: mixed. Effective date: 2025-02-06. Last review date: 2025-07-01.

Medicare vs non‑Medicare guidance: For Medicare members, follow CMS National Coverage Determination 50.3 (Cochlear Implantation). For non‑Medicare members, Kaiser Permanente uses the MCG Cochlear Implant guideline (KP-0177) for medical necessity determinations; documentation to support non‑Medicare requests includes the most recent audiogram/hearing test and the most recent clinical notes from the requesting provider.

Key facts

Policy subjectCochlear Implant (including Hybrid Cochlear Implant)

Coverage stanceMixed — standard cochlear implants may be medically necessary per criteria; hybrid cochlear implants are considered not covered (insufficient evidence)

Effective date2025-02-06

Last review2025-07-01

Medical‑Necessity Criteria

Cochlear Implant - General statement

Cochlear Implant Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

Guidance by payer type: Criteria in the applicable policy statements (for Medicare members: follow CMS NCD Cochlear Implantation (50.3); for non-Medicare members: Kaiser Permanente uses MCG Cochlear Implant (KP-0177 12012022v2) guideline for medical necessity determinations)
Supporting documentation requirement: Submit supporting documentation: most recent audiogram/hearing test and most recent clinical notes from requesting provider

Billing and codes: Covered codes include CPT 69930 (cochlear device implantation, with or without mastoidectomy) and HCPCS L8614, L8619, L8627, L8628 for cochlear device and components.

Not Covered / Experimental

Hybrid cochlear implant determination: Hybrid devices (for example, the Nucleus Hybrid L24) are considered not covered. The MTAC/MPC evidence review concluded there is insufficient evidence to support effectiveness or safety compared with standard cochlear implants, and that use of hybrid cochlear implants does not meet Kaiser Permanente Medical Technology Assessment Criteria.

Historical housekeeping: The following CPT codes have been removed or are listed as non‑applicable historically: 69714, 69715, 69717, 69718.

Coding

Covered CPTCPTCovered

69930

Cochlear device implantation, with or without mastoidectomy

Covered HCPCS / Cochlear device & componentsHCPCSCovered

L8614	Cochlear device - includes all internal and external components
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

Hybrid Cochlear Implant Not Covered when billed withHCPCSNot Covered

L8614

Cochlear device - includes all internal and external components (listed as trigger for not-covered hybrid billing)

Removed / Non-applicable CPT codes (historical)CPTNot Covered

69714	Removed - non-applicable
69715	Removed - non-applicable
69717	Removed - non-applicable
69718	Removed - non-applicable

Provider Actions

Documentation Required

Submit supporting documentation for non-Medicare determinations

When requesting cochlear implantation for non‑Medicare members, submit the most recent audiogram/hearing test and the most recent clinical notes from the requesting provider to support medical necessity determinations.

Prior Authorization

Preauthorization code check

Verify authorization requirements for the specific code and plan type by using the Pre-authorization Code Check before submitting the request.

Documentation Required

MCG criteria access

Kaiser Permanente uses the MCG Cochlear Implant guideline (KP-0177) for non‑Medicare medical necessity determinations. MCG manuals are proprietary, but providers may request a copy of the specific criteria document used in a utilization management decision by calling Kaiser Permanente Clinical Review staff.

Background & Evidence

Background: A cochlear implant is an electronic device with an internal implanted component and an external speech processor that can enable patients with severe to profound sensorineural hearing loss to perceive sound; implantation requires surgery and substantial post‑implantation therapy. Provision of unilateral cochlear implants is standard practice, with growing interest in bilateral implantation to improve hearing in noise, sound localization, and speech perception, though bilateral implants currently function independently and bilateral coordination has limitations. Hybrid cochlear implant technology (for example the Nucleus Hybrid L24) combines acoustic amplification for low frequencies with cochlear implant stimulation for high frequencies using a shorter electrode array; the first hybrid cochlear implant received FDA approval in March 2014. The published evidence base for hybrid implants is limited.

Evidence conclusion for hybrid implants: Insufficient evidence to support effectiveness or safety compared with standard cochlear implants; does not meet Kaiser Permanente Medical Technology Assessment Criteria.

Definitions

Medicare Determinations

Revision History

revisedLatest

Hybrid cochlear implant criteria: determined to be not covered due to insufficient evidence to support effectiveness/safety compared with standard cochlear implants.

02/06/2025removed

Removed MTAC Reviews on Bilateral Cochlear Implants from 2004 and 2006 as it is no longer applicable and covered using KP/MCG Guidelines.

2015–2025revised