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    v1.0.31
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)North Dakota DME Cochlear Policy Update | OpenPaye…
    Ask Trek AI about this page
    ModifiedNorth Dakota Department of Health & Human ServicesPolicy N/A

    Cochlear Implants and Auditory Osseointegrated Implants (BAHA) Replacement Parts/Repair

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    This policy governs North Dakota Medicaid DME coverage, prior authorization, documentation, and limitations for replacement parts and repairs for cochlear implants and auditory osseointegrated implants (BAHA). Implant devices and implant procedures themselves are not reimbursed under the DME program.

    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyCochlear Implants and Auditory Osseointegrated Implants (BAHA) Replacement Parts/Repair
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJuly 1, 2014
    Next Review DateN/A
    Key ActionSubmit replacement-part and repair requests for service authorization with documentation supporting medical necessity, equipment identification, purchase date, warranty status, and requested units.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    The policy clarifies that DME coverage is limited to cochlear and BAHA replacement parts and repairs and excludes reimbursement for the implant device and procedure.

    Replacement HCPCS codes, allowable quantities, and replacement restrictions were revised or added.

    A BAHA programming code was added to the policy history as an allowable code.

    The policy history records removal of a non-covered restriction concerning switching from a body-worn external sound processor to a behind-the-ear model.

    The non-covered exclusion for switching from a body-worn external sound processor to a behind-the-ear model was deleted.

    YesService authorization required
    3 yearsSpeech processor warranty period
    12 monthsMinimum processor use
    5 yearsExternal sound processor replacement
    33/monthAlkaline batteries
    Not coveredManufacturer upgrades

    Coverage Criteria

    Cochlear or BAHA Replacement Parts and Repairs

    Covered when ALL of the following conditions are met:

    ALL of the following

    • The cochlear or BAHA device is in continuous use and still meets the member's needs.
    • A certified audiologist has established a plan of care and substantiates the need for the repairs.
    • The repairs are necessary to allow the device to be functional.
    • The device being repaired is FDA-approved and meets all Medicaid standards of coverage.

    Speech Processor Replacement

    For speech processor replacement, ALL of the following additional conditions must be met:

    ALL of the following

    • The speech processor is out of the three-year warranty period.
    • The speech processor is irreparable.

    Service Authorization and Code-Specific Limits

    Service authorization is required for cochlear/BAHA replacement parts. Code-specific purchase or replacement limits apply as follows:

    Service authorization is required for cochlear/BAHA replacement parts.
    E1399 — Orthotic and prosthetic supply, accessory, and/or service component of another item: allowable units are based on review.
    L8691 — Auditory osseointegrated device, external sound processor, replacement, body worn, including headband or other means of attachment: allows 1 replacement every 5 years.
    L8621 — Zinc battery replacement, cochlear implant device: subject to applicable review and purchase limits.
    L8622 — Alkaline battery, replacement, any size, cochlear implant device: allows 33 batteries per month.
    L8623 — Lithium-ion battery, replacement, cochlear implant device speech processor, ear level: allows 1 battery every 2 years.

    ND Medicaid does not reimburse the cost of cochlear or BAHA implants or implant procedures under the Durable Medical Equipment (DME) program.

    Reimbursement is not made for manufacturer upgrades. Upgrades for aesthetic improvement, a smaller profile, technological advances in hardware, or convenience are not considered medically necessary and will not be approved.

    V5241 is not covered because this dispensing fee is specific to hearing aids.

    Upgrades to a speech processor for aesthetic improvement, a smaller-profile component, technological advances in hardware, or convenience are not covered.

    Medical Necessity

    Medical Necessity for Replacement Parts or Repair

    Covered when all of the following are met:

    All medical necessity conditions required

    • The device is continuously used and continues to meet the member's needs.
    • A certified audiologist has established a plan of care.
    • The certified audiologist substantiates the need for the repair.
    • The repair is necessary to make the device functional.
    • The device being repaired is FDA-approved and meets all Medicaid standards of coverage.

    Covered and Non-Covered Codes

    Replacement codes and code-specific allowable limitsHCPCSCovered
    E1399Orthotic and prosthetic supply, accessory, and/or service component of another L; allowable units based on review
    L8691Auditory osseointegrated device, external sound processor, replacement, body worn, includes headband or other means of attachment; 1 replacement every 5 years
    L8621Zinc battery replacement - cochlear implant device
    L8622Alkaline battery, replacement, any size - cochlear implant device; 33 batteries per month
    L8623Lithium-ion battery, replacement, cochlear implant device speech processor, ear level; 1 battery every 2 years
    L8624Lithium-ion battery, replacement, cochlear implant; 4 replacements per year
    Other replacement HCPCS codes referenced by policy historyHCPCSCovered
    L7368Allowable replacement code; description not provided in the document excerpt
    L8627Allowable replacement code; description not provided in the document excerpt
    L8628Allowable replacement code; description not provided in the document excerpt
    L8619Allowable replacement code; description not provided in the document excerpt
    L8617Allowable replacement code; description not provided in the document excerpt
    L8618Allowable replacement code; description not provided in the document excerpt
    BAHA programmingCPTCovered
    92700BAHA programming
    Not coveredHCPCSNot Covered
    V5241Dispensing fee specific to hearing aids
    Replacement HCPCS CodesHCPCSCovered
    E1399Orthotic and prosthetic supply, accessory, and/or service component of another L
    L8691Auditory osseointegrated device, external sound processor, replacement, body worn, includes headband or other means of attachment
    L8621Zinc battery replacement - Cochlear implant device
    L8622Alkaline battery, replacement, any size - Cochlear implant device
    L8623Lithium-ion battery, replacement cochlear implant device, speech processor, ear level
    L8624Lithium-ion battery, replacement, cochlear implant device
    L7368Battery recharger unit for lithium-ion rechargeable batteries
    L8627Cochlear implant, external speech processor, component replacement
    L8628Cochlear implant, external controller component, replacement
    L8619Cochlear implant, external speech processor, replacement
    1–10 of 15
    1/2
    Replacement and Repair Procedure CodeCPTCovered
    92700Unlisted otorhinolaryngological procedure
    Replacement limit
    HCPCS codeL8691
    ItemExternal sound processor replacement
    Replacement interval1 replacement every 5 years
    Replacement limit
    HCPCS codeL8622
    ItemAlkaline cochlear implant batteries

    Authorization and Coverage Risk

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for replacement or repair of a sound processor. Submit the required service authorization request and supporting documentation before services are provided.

    • Applies to sound processor replacement and repair.
    Prior Authorization

    Service Authorization Required

    Service authorization is required for cochlear implant and auditory osseointegrated implant (BAHA) replacement parts and repairs.

    • Include authorization for applicable cochlear implant and BAHA replacement parts or repair services.
    Documentation Required

    Device and Service Context

    Cochlear implants and auditory osseointegrated implants, also known as BAHA, use external components to support hearing. These components include sound or speech processors and batteries. This policy addresses replacement parts and repairs needed to keep an existing device functional, subject to continuous use, ongoing member need, and a certified audiologist's plan of care.

    Replacement Limits

    Replacement limit
    HCPCS codeE1399
    ItemOrthotic and prosthetic supply, accessory, and/or service component of another L
    Allowable unitsBased on review
    Replacement limit
    HCPCS codeL8691
    ItemAuditory osseointegrated device external sound processor, body worn
    Replacement interval1 replacement every 5 years

    Required Documentation

    Documentation Required

    Assemble complete replacement or repair documentation

    Document the need for the replacement part or repair and identify the equipment before requesting authorization. Include the brand name, model number, purchase date, warranty copy, evidence that the item is out of warranty, labor invoice, and requested units per HCPC when repair units are requested; a manufacturer’s invoice is required for off-site repairs.

    • Brand name and model number
    • Purchase date and warranty copy
    • Evidence that the item is out of warranty
    • Labor invoice identifying the item
    • Number of units required per HCPC, when repair units are requested
    • Manufacturer’s invoice for off-site repairs
    Prior Authorization

    Submit for service authorization

    Submit the replacement-part or repair request for service authorization. Replacement and repair of a sound processor specifically require prior authorization.

    Non-Covered Services and Items

    The DME program does not cover cochlear or BAHA implant devices or the related implant procedures. It also excludes manufacturer upgrades for aesthetic improvement, smaller-profile components, technological advances in hardware, or convenience; upgrades to speech processors for these purposes are not medically necessary. V5241, a hearing-aid dispensing fee, is also not covered.

    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyCochlear Implants and Auditory Osseointegrated Implants (BAHA) Replacement Parts/Repair
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateJuly 1, 2014
    Next Review DateN/A
    Key ActionSubmit replacement-part and repair requests for service authorization with documentation supporting medical necessity, equipment identification, purchase date, warranty status, and requested units.
    SourceLink
    On This Page
    Coverage CriteriaMedical NecessityCovered and Non-Covered CodesAuthorization and Coverage RiskDevice and Service ContextReplacement LimitsRequired DocumentationNon-Covered Services and Items
    L8624 — Lithium-ion battery, replacement, cochlear implant device: allows 4 replacements per year.
    Monthly quantity limit33 batteries per month
    Replacement limit
    HCPCS codeL8623
    ItemLithium-ion cochlear implant battery
    Replacement interval1 battery every 2 years
    Replacement limit
    HCPCS codeL8624
    ItemLithium-ion cochlear implant battery replacements
    Annual limit4 replacements per year
    Replacement limit
    Device typeBAHA external sound processor
    ComponentExternal sound processor
    Replacement interval1 replacement every 5 years
    Replacement limit
    Battery typeAlkaline cochlear implant batteries
    DeviceCochlear implant
    Monthly quantity limit33 batteries per month
    Replacement limit
    Battery typeLithium-ion battery
    Processor typeEar-level speech processor
    Replacement interval1 battery every 2 years
    Replacement limit
    Battery typeLithium-ion battery
    DeviceCochlear implant
    Annual replacement limit4 replacements per year
    Replacement limit
    ComponentLithium-ion battery recharger unit
    UseLithium-ion rechargeable batteries
    Replacement interval1 replacement every 2 years
    Replacement limit
    ComponentCochlear implant external speech processor component
    Replacement typeComponent replacement
    Replacement interval1 replacement every 3 years
    Replacement limit
    ComponentCochlear implant external controller component
    Replacement typeComponent replacement
    Replacement interval1 replacement every 2 years
    Replacement limit
    ComponentCochlear implant transmitting coil
    Replacement typeTransmitting coil replacement
    Replacement interval1 replacement every 6 months
    Replacement limit
    ComponentCochlear implant transmitter cable
    Replacement typeTransmitter cable replacement
    Replacement interval1 replacement every 6 months
    Replacement limit
    ComponentIntegrated cochlear implant transmitting coil and cable
    Replacement typeIntegrated replacement
    Replacement limit4 replacements per 6 months
    Request limit
    ProcedureUnlisted otorhinolaryngological procedure
    Code92700
    Requests-per-device limit2 requests per device per year

    Replacement or Repair Justification

    Document the need for the requested replacement part or repair, including the device’s brand name and model number. The processor must have been used for at least 12 months before the unit is considered for replacement.

    • A certified audiologist must establish a plan of care and substantiate the need for repairs.
    • Repairs must be necessary to make the device functional.
    Documentation Required

    Purchase and Warranty Documentation

    The service authorization request must include evidence of the purchase date and show that the requested item is out of warranty. Include a copy of the warranty.

    • For speech processor replacement, the processor must be out of the three-year warranty and irreparable.
    Documentation Required

    Labor Invoice and Unit Detail

    Submit a labor invoice stating which item needs replacement or repair. If repair units are requested, specify the number of units required per HCPCS code.

    • The request must identify the repair unit detail and requested quantity for each HCPCS code.
    Documentation Required

    Off-Site Repair Invoice

    If the item must be repaired off-site, include the manufacturer’s invoice with the request.

    • Manufacturer documentation is required for off-site repairs.
    Denial Risk

    Coverage Conditions Must Be Met

    Coverage may be denied when the device or repair does not meet the policy’s coverage and medical-appropriateness conditions.

    • The device must be in continuous use and still meet the member’s needs.
    • The device being repaired must be FDA-approved and meet Medicaid standards of coverage.
    • A certified audiologist must establish a plan of care and substantiate the need for repairs.
    • Repairs must be necessary to allow the device to function.
    Denial Risk

    Speech Processor Must Be Irreparable

    A speech processor replacement request may be denied if the processor is still under warranty or can be repaired. Replacement requires that the processor be out of the three-year warranty and irreparable.

    • Do not request replacement when the speech processor remains under warranty.
    • Document why repair is not possible.
    Denial Risk

    Upgrade Rather Than Medically Necessary Replacement

    Manufacturer upgrades are not reimbursable. An upgrade of a speech processor for aesthetic improvement, smaller-profile components, technological advances in hardware, or convenience is not medically necessary and will not be approved.

    • Request replacement only when medically necessary and supported by the coverage criteria, not when the request is for an upgrade.
    Billing Rule

    Hearing-Aid Dispensing Fee Not Covered

    HCPCS code V5241 is not covered because the dispensing fee is specific to hearing aids.

    • Do not bill V5241 for cochlear implant or BAHA replacement parts.
    Billing Rule

    Quantity and Frequency Limits

    Apply the code-specific purchase and replacement limits when requesting cochlear implant or BAHA replacement parts. Requests exceeding an applicable limit require review and may not be covered.

    • L8691: 1 replacement every 5 years.
    • L8622: 33 batteries per month.
    • L8623: 1 battery every 2 years.
    • L8624: 4 replacements per year.
    • L7368: 1 replacement every 2 years.
    • L8627: 1 replacement every 3 years.
    • L8628: 1 replacement every 2 years.
    • L8617: 1 replacement every 6 months.
    • L8618: 1 replacement every 6 months.
    • L8629: 4 replacements per 6 months.
    • L7520 and E1399: allowable units based on review; 92700 allows 2 requests per device per year.
    Replacement limit
    HCPCS codeL8622
    ItemAlkaline cochlear implant battery
    Monthly quantity limit33 batteries per month
    Replacement limit
    HCPCS codeL8623
    ItemLithium-ion cochlear implant battery
    Replacement interval1 battery every 2 years
    Replacement limit
    HCPCS codeL8624
    ItemLithium-ion cochlear implant battery
    Annual replacement limit4 replacements per year
    Replacement limit
    DeviceBAHA external sound processor
    ComponentExternal sound processor
    Replacement interval1 replacement every 5 years
    Replacement limit
    Battery typeAlkaline cochlear implant batteries
    DeviceCochlear implant
    Monthly quantity limit33 batteries per month
    Replacement limit
    Battery typeLithium-ion battery
    Processor typeEar-level cochlear implant speech processor
    Replacement interval1 battery every 2 years
    Replacement limit
    Battery typeCochlear implant lithium-ion battery
    DeviceCochlear implant
    Annual replacement limit4 replacements per year
    Replacement limit
    ComponentLithium-ion battery recharger unit
    UseLithium-ion rechargeable batteries
    Replacement interval1 replacement every 2 years
    Replacement limit
    ComponentExternal speech processor component
    DeviceCochlear implant
    Replacement interval1 replacement every 3 years
    Replacement limit
    ComponentExternal controller component
    DeviceCochlear implant
    Replacement interval1 replacement every 2 years
    Replacement limit
    ComponentTransmitting coil
    DeviceCochlear implant
    Replacement interval1 replacement every 6 months
    Replacement limit
    ComponentTransmitter cable
    DeviceCochlear implant
    Replacement interval1 replacement every 6 months
    Replacement limit
    ComponentIntegrated transmitting coil and cable
    DeviceCochlear implant
    Replacement limit4 replacements per 6 months
    Request limit
    ProcedureUnlisted otorhinolaryngological procedure
    Code92700
    Request limit2 requests per device per year