Hearing services: cochlear implants and auditory osseointegrated devices (AODs)
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Rules governing Medicaid coverage, clinical documentation, and prior authorization requirements for cochlear implants and implantable/non-implantable auditory osseointegrated devices (AODs) for Mississippi Medicaid beneficiaries.
Cochlear implant coverage criteria and age-specific documentation requirements were restated and organized (unilateral and bilateral criteria, exclusions, device billing, DME rules, and rehabilitation documentation).
Definitions and coverage rules for implantable and non-implantable auditory osseointegrated devices (AODs), including age limits, indications, and non-coverage items, were codified.
Provider enrollment requirements were updated to reference Miss. Admin. Code Title 23, Part 200, Chapter 4.
Coverage Criteria for Cochlear Implants and AODs
Cochlear Implant Coverage Criteria
Covered when ALL of the following general criteria are met for unilateral cochlear implantation.
General eligibility for unilateral cochlear implantation
- Audiologic severity: Severe to profound sensorineural hearing loss in both ears as defined by FDA criteria with lack of benefit from a well-fitting aid
Chunk 3.1
- Patient factors: Cognitive ability to use auditory clues, patient motivation and willingness to undergo an extended program of rehabilitation
Chunk 3.2
- Anatomic/medical suitability: Freedom from middle ear infection; an accessible cochlear lumen structurally suited to implantation; freedom from lesions in the auditory nerve and central acoustic areas; and no contraindications to surgery
Chunk 3.3-3.4
- Device labeling: Device must be used in accordance with FDA approved labeling
Chunk 3.5
Chunk 3.C
Chunk 4.D
Implantable AOD Coverage Criteria
Covered when ALL of the following are met for implantable AODs:
Chunk 7.A.1
Chunk 7.A.2
Non-implantable AOD Coverage Criteria
Covered when ALL of the following are met for non-implantable AODs:
Chunk 8.1
Chunk 8.2
Cochlear implant devices are not reimbursed through the Durable Medical Equipment (DME) program. The device cost must be billed by the hospital using the usual inpatient or outpatient hospital reimbursement methodology. Claims that bill the cochlear implant device outside of an inpatient or outpatient hospital setting (including billing through DME) risk denial because the device payment is the hospital’s responsibility. Medicaid does not provide additional device benefits if the surgical procedure is performed in other outpatient settings.
Certain items related to auditory osseointegrated devices (AODs) and cochlear implants are explicitly excluded as non‑medically necessary. Non‑implantable AODs are not covered for bilateral sensorineural hearing loss, and the Division does not cover replacement of lost or stolen processors. In addition, non‑medically necessary accessories for non‑implantable AODs are excluded from coverage. Batteries, repairs, and external replacement parts for implantable and non‑implantable AODs are covered per Part 209, Rule 1.24, but non‑medically necessary accessories remain non‑covered.
Provider Requirements, Documentation, and Authorization
Obtain prior authorization for non‑implantable AODs
Prior authorization (PA) is required for non-implantable auditory osseointegrated devices (AODs). Obtain PA from a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or the Division’s designee before submitting claims for non-implantable AODs.
Document failure of appropriately fitted air‑conduction hearing aids
Document and demonstrate failure or lack of benefit from appropriately fitted air‑conduction hearing aids where applicable before approval of a cochlear implant or an AOD; this conservative management must be shown in the clinical record when criteria call for prior demonstration of aid failure.
Surgeon/audiologist documentation for cochlear implant medical necessity
The surgeon and/or audiologist must document the severity of sensorineural hearing loss per FDA criteria, lack of benefit from a well‑fitting hearing aid, cognitive ability to use auditory cues, patient motivation and willingness to undergo rehabilitation, freedom from middle ear infection and cochlear/nerve lesions, absence of surgical contraindications, and adherence to FDA labeling.
Meet pediatric and adult documentation requirements
Follow age‑specific documentation rules: for children (12 months–17 years) document onset period (pre‑ or post‑linguistic) and bilateral severe-to-profound sensorineural deafness demonstrated by inability to improve on age‑appropriate closed‑set word ID tasks with amplification or lack of progress in auditory training; for adults (≥18 years) document onset period and, for post‑lingual adults, current FDA‑recommended sentence recognition scores from tape‑recorded tests in the beneficiary’s best listening condition.
Record rehabilitative services and retain in the medical record
Document rehabilitative services that support the medical necessity of the cochlear implant or AOD and retain that documentation in the beneficiary’s medical record for review.
Denial risk if prior authorization is not obtained
Non‑implantable AOD claims submitted without prior authorization from a UM/QIO, the Division of Medicaid, or a designee may be denied—ensure required PA is obtained and documented before claim submission.
Bill cochlear implant device through the hospital only
The cochlear implant device cost must be billed by the inpatient or outpatient hospital; claims for the device billed through Durable Medical Equipment (DME) or billed outside hospital inpatient/outpatient settings risk denial because device payment is not covered via DME.
Definitions
Background
Cochlear implants and auditory osseointegrated devices restore or augment hearing through mechanical or electrical transmission to the inner ear. A cochlear implant bypasses damaged hair cells by directly stimulating the auditory nerve via implanted electrodes, enabling perception of sound for individuals with severe to profound sensorineural hearing loss. Implantable AODs transmit sound vibrations by direct bone conduction through the skull to the inner ear and are indicated for conductive, mixed, or single‑sided sensorineural hearing loss in beneficiaries meeting FDA labeling and audiologic criteria. Patient selection requires assessment of anatomic suitability, lack of benefit from appropriately fitted air‑conduction hearing aids where applicable, absence of active middle ear infection or contraindications to surgery, and the ability and willingness to participate in postoperative rehabilitation. For cochlear implants, Medicaid covers subsequent contralateral implantation in defined circumstances (for example, bilateral profound deafness not meeting communication goals with a unilateral implant, prelingually deaf children who would substantially benefit, or certain cases of auditory neuropathy) but will not cover bilateral implantation when the lesser affected ear can be sufficiently augmented by a hearing aid or could later benefit from other interventions.
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