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.

CurrentProvidence Health PlanPolicy 127

Cochlear Implants and Auditory Brainstem Implants

Customize your policy alerts

Sign up for Providence Health Plan Policy 127 alerts

Get alerted when Policy 127 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity, coverage criteria, and exclusions for cochlear implants, hybrid cochlear implants, and auditory brainstem implants across Company products with notes for Commercial, Medicaid/OHP, and Medicare applicability.

Policy Summary

PayerProvidence Health Plan

PolicyCochlear Implants and Auditory Brainstem Implants

Policy CodePolicy 127

Change TypeAnnual review — no material changes

Effective DateJun 1, 2026

Last ReviewAug 1, 2024

Next Review DateMay 1, 2027

Key ActionObtain prior authorization to verify the member meets medical necessity criteria including age, audiometric thresholds, documented hearing‑aid trial or limited benefit, and rehabilitation participation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

17 yrsChildren up to

18+Adults

≥90 dBPediatric threshold

≥70 dBAdult PTA threshold

1ABI approved devices

L9900Never allowed code

Coverage Criteria for Cochlear and Auditory Brainstem Implants

Initial pediatric cochlear implantation

Covered when ALL of the following are met

Pediatric Cochlear Implant (I): A. Diagnosed unilateral or bilateral profound sensorineural hearing loss with thresholds of 90 dB or greater at 1000 Hz; AND B. Limited or no benefit from properly fitted bilateral hearing aids defined by at least one of the following: (1) For younger children (up to 4 years): (a) quantifiable lack of progress in development of simple auditory skills with appropriate amplification; AND (b) participation in intensive aural habilitation over a 3–6 month period; OR (2) For older children (5–17 years): ≤30% correct on open-set tests (e.g., MLNT or LNT) depending upon cognitive and linguistic skills; AND C. Patient and/or caregiver able to participate in a post-implant rehabilitation program; AND D. Patient is an appropriate candidate for cochlear implantation and has none of the following contraindications: (1) absent cochlear nerve or cochlear development on imaging; (2) deafness due to damage to the acoustic nerve or central auditory pathway; (3) active or chronic infections of the middle ear or mastoid cavity; (4) tympanic membrane perforation at the time of the procedure.

Initial adult cochlear implantation

Covered when ALL of the following are met

Adult Cochlear Implant (III):

Policy Summary

PayerProvidence Health Plan

PolicyCochlear Implants and Auditory Brainstem Implants

Policy CodePolicy 127

Change TypeAnnual review — no material changes

Effective DateJun 1, 2026

Last ReviewAug 1, 2024

Next Review DateMay 1, 2027

SourceLink

On This Page

Hybrid cochlear implantation

Covered when ALL of the following are met

Hybrid Cochlear Implant (X): A. Patient is 18 years of age or older; AND B. Bilateral severe-to-profound high-frequency sensorineural hearing loss with residual low-frequency hearing sensitivity; AND C. Limited benefit from appropriately fit bilateral hearing aids; AND D. Normal to moderate low-frequency hearing in the ear selected for implantation (thresholds no poorer than 60 dB HL up to and including 500 Hz); AND E. Severe-to-profound mid-to-high-frequency hearing loss in the ear to be implanted (average of 2000, 3000, 4000 Hz ≥75 dB HL); AND F. Contralateral ear with moderately severe to profound mid-to-high-frequency loss (average ≥60 dB HL); AND G. Preoperative CNC word recognition in the ear to be implanted between 10% and 60% inclusive, and contralateral ear score equal to or better than the ear to be implanted but not >80% best-aided; AND H. Patient has none of the following contraindications: (1) deafness due to lesions of the acoustic nerve or central auditory pathway; (2) active middle ear disease (with or without tympanic membrane perforation); (3) absence of cochlear development; (4) duration of severe-to-profound hearing loss ≥30 years.

Covered indications per device labeling

Covered when device-specific FDA labeled indications and supporting clinical criteria are met

Device-specific age and diagnosis: Patient meets the FDA-labeled age and diagnostic criteria for the selected device (e.g., pediatric age thresholds, adults ≥18 for hybrid devices, ABI for age ≥12 with NF2)see device labeling

FDA-labeled indications are described in Tables 1–3 and ABI table

Degree/configuration of hearing loss: Patient has the degree and configuration of sensorineural hearing loss specified by the device labeling (examples: bilateral severe-to-profound, residual low-frequency hearing with high-frequency loss for hybrid devices, SSD/AHL criteria)see device labeling (PTA, frequency-specific thresholds)

Includes PTA and frequency-specific threshold requirements

Limited benefit from appropriately fitted hearing aids: Patient demonstrates limited benefit from appropriately fitted binaural hearing aids as quantified by device-specific speech perception scores or lack of auditory progress after appropriate amplification and aural habilitationexamples include HINT ≤40% best-aided, MLNT/LNT ≤30% or <20% depending on age, CNC thresholds per labeling

A 3–6 month hearing-aid trial is recommended for candidates without prior aided experience unless contraindicated (e.g., cochlear ossification)

Contraindications absent or addressed: No contraindications listed in device labeling (e.g., lesions of acoustic nerve for hybrid implants, active middle ear disease, anatomical issues preventing placement, intolerance to implant materials, unstable psychological status)device labeling

ABI labeling notes that preoperative audiological criteria are not relevant when tumor excision eliminates residual hearing

Coverage evidence nodes for unilateral and bilateral cochlear implants

Evidence-supported coverage considerations derived from reviews and trials

Adults - Bilateral CI benefit: Bilateral cochlear implants improve sound localization and speech perception in noise compared with unilateral implants; trials and systematic reviews support benefit for postlingual severe-to-profound bilateral sensorineural hearing loss in adults able to undergo auditory rehabilitation.

Hayes B rating; van Schoonhoven and Crathorne systematic reviews consistent with benefit

Adults - Limited evidence: Insufficient evidence for bilateral CI efficacy in prelingually deafened adults, adults with only moderate deafness, or adults with significant non-hearing disabilities.

Hayes D2 rating

Adults - Unilateral CI: Unilateral cochlear implants provide significant benefit over hearing aids for adults with severe-to-profound sensorineural hearing loss and appear cost-effective in identified studies; duration of deafness impacts outcomes.

Supported by Bond and other reviews

Pediatrics - Timing: Earlier implantation (particularly <12 or <18 months) is associated with better communicative outcomes and earlier open-set speech; implantation under 37 months shown to be safe with low complication rates.

Forli, Hoff and Hayes studies report advantages and safety

Pediatrics - Bilateral CI: Bilateral cochlear implantation in children improves sound localization and hearing in noise compared with unilateral implants; some evidence suggests benefits for preverbal communication and language development though randomized trials are lacking.

Best-evidence syntheses and systematic reviews indicate consistent benefits for localization and variable results for speech/language domains

Evidence-based coverage observations (no formal criteria stated)

Summaries of when benefit is most consistently observed (evidence-based observations):

Bilateral implantation benefits: Bilateral cochlear implantation in children is associated with improved localization, turn-taking vocal behaviors, and preverbal communication compared with unilateral implants; earlier acoustic experience and implantation (<12 months) are associated with better outcomes.

Supported by prospective and retrospective studies

Cochlear implants for SSD/UHL: Systematic reviews and meta-analyses report clinically significant improvements in speech perception, localization, tinnitus suppression, and quality of life for SSD/UHL patients, but evidence is limited by small sample sizes, heterogeneity, and risk of bias; shorter duration of deafness and acquired SSD associated with better outcomes.

Supported by ECRI, Benchetrit, Levy reviews

Auditory brainstem implant utility: ABIs offer limited hearing rehabilitation for patients without a functional cochlear nerve (e.g., NF2), improving differentiation of speech and environmental sounds and lip-reading aided perception; outcomes may improve over years.

Supported by systematic reviews and nonrandomized studies

Hybrid cochlear implant considerations: Hybrid implants may preserve low-frequency hearing and improve speech perception in selected patients but carry substantial risk of losing residual hearing and the overall evidence quality is low; long-term outcomes are uncertain.

Hayes review rated hybrid evidence C

Coverage rationale and indications

Coverage is aligned with professional society guidance and FDA indications for cochlear implants and auditory brainstem implants.

General coverage rationale: Cochlear implants are considered effective and safe for children and adults with severe-to-profound bilateral sensorineural hearing loss who meet FDA-approved indications; bilateral implants provide improved localization and hearing in noise compared to unilateral implants.

Supported by evidence summary and guidance from AAA, AAO-HNS, NICE, and AAP

Special populations: Children (≥12 months) with bilateral severe-to-profound sensorineural hearing loss who fail to progress with appropriately fitted amplification, adults and children who fail an appropriately fit hearing aid trial, and selected patients with unilateral profound hearing loss may be candidates when documented criteria are met.

Referenced in professional society statements

Auditory brainstem implant indication: Auditory brainstem implants are an option for patients (e.g., NF2) with auditory nerve damage who are not candidates for cochlear implants when performed by experienced teams with appropriate governance.

NICE interventional guidance and systematic reviews support use in select patients

Billing and Coding

FDA-approved devices (Table 1)mixed

HiResolution Bionic Ear System	HiResolution ™ Bionic Ear System — FDA-labeled indications for adults (18+) and children (12 months through 17 years) as listed in Table 1
Advanced Bionics Naida/Sky (examples: Naida CI M30, Naida CI M90, Sky CI M90)	Advanced Bionics devices — FDA-labeled indications include severe-to-profound bilateral sensorineural hearing loss (>70 dB) with limited benefit from appropriately fitted hearing aids; pediatric labeling includes specified hearing-aid trial durations and criteria
Cochlear Nucleus Cochlear Implant System	Cochlear ™ Nucleus® Cochlear Implant System — FDA-labeled indications for individuals 18+ with bilateral sensorineural hearing impairment and device-specific definitions of limited benefit from hearing aids
Med-EL Cochlear Implant System	Med-EL® Cochlear Implant System — FDA-labeled indications include bilateral severe to profound sensorineural hearing loss (PTA ≥70 dB) and specified criteria for single-sided deafness/asymmetric hearing loss for ages 5+; pediatric criteria and hearing-aid trial requirements noted

CPT CodesCPT

92640	Diagnostic analysis with programming of auditory brainstem implant, per hour
69930	Cochlear device implantation, with or without mastoidectomy
69949	Unlisted procedure, inner ear

HCPCS CodesHCPCS

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, replacement
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
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
L9900	Orthotic and prosthetic supply, accessory, and/or service component of another (HCPCS 'L' code)

1–10 of 11

1/2

Mixed/Othermixed

(see device labeling)

Refer to device-specific PMA labeling in Table 1 for exact device-model level indications and testing thresholds

Policy Notesmixed

L9900	HCPCS L9900 is never allowed for separate reimbursement (billing pitfall - will be denied)
S2235	HCPCS S2235 is not recognized for claim submission per company coding policy

Billing and coding tables (updated)mixed

No codes listed

inv-26: Audiometric and speech perception thresholds — PTA and speech-recognition thresholds by age group

Pediatric profound thresholdChildren: diagnosed unilateral or bilateral profound SNHL with thresholds ≥90 dB at 1000 Hz

Adult severe-to-profound PTAAdults: pure tone average (500, 1000, 2000 Hz) ≥70 dB HL

Adult speech-recognition thresholdAdults: limited or no benefit from hearing aids defined as ≤50% correct on tape-recorded open-set sentence recognition tests

Pediatric speech-perception thresholdOlder children (5–17 years): ≤30% correct on open-set tests (e.g., MLNT/LNT) depending on cognitive/linguistic skills

inv-27: Speech recognition test thresholds — examples (MLNT/LNT, HINT, CNC)

MLNT / LNT (children)Multisyllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT): older children meeting criterion often demonstrate ≤30% correct on open-set testing

HINT (adults)Hearing In Noise Test (HINT) sentences: device labeling and examples reference best-aided HINT sentence scores (e.g., ≤40% in some device indications)

CNC (hybrid devices)Consonant-Nucleus-Consonant (CNC) word recognition: preoperative CNC word scores specified in hybrid device labeling (e.g., 10–60% in ear to be implanted; contralateral ear ≤80% best-aided)

inv-28: Pure tone average (PTA) — example thresholds and device-specific references

Example adult PTA thresholdPure tone average example for adults: PTA ≥70 dB HL at 500, 1000, and 2000 Hz (policy adult CI criterion)

Hybrid device low-frequency requirementDevice-specific low-frequency thresholds for hybrid implants: normal to moderate low-frequency hearing no poorer than 60–65 dB HL up to 500 Hz (per hybrid labeling)

Hybrid device high-frequency requirementHybrid device mid–high frequency requirement: average thresholds (e.g., 2000, 3000, 4000 Hz) ≥75 dB HL (device-specific labeling examples)

inv-29: Pure tone average threshold referenced by AAA — approximate 90 dB HL reference

AAA referenced PTAAmerican Academy of Audiology (AAA) guidance generally indicates a pure tone average (500, 1000, 2000 Hz) of approximately 90 dB HL or greater as indicative of profound hearing loss in both ears

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Obtain prior authorization to confirm medical necessity

Prior authorization is required to verify that the member meets the policy's medical necessity criteria, including age, audiometric thresholds, documented limited benefit from appropriately fitted bilateral hearing aids, assessment of contraindications, and participation ability in post‑implant rehabilitation.

Verify age per applicable criteria (children up to 17 years; adults 18+; ABI ≥12 years).
Confirm audiometric thresholds (e.g., pediatric ≥90 dB at 1000 Hz; adult PTA ≥70 dB at 500/1000/2000 Hz).
Document limited or no benefit from properly fitted bilateral hearing aids as defined by device/age‑specific speech scores.

Prior Authorization

Verify device FDA‑labeled indications and supply labeled criteria

Prior authorization should confirm that the requested device meets its FDA‑labeled indications (age, degree/configuration of hearing loss, and device‑specific speech perception thresholds) and that supporting evidence (e.g., device labeling in Table 1–3) is provided.

Include device name and manufacturer and cite the FDA‑labeled age and audiologic criteria from Table 1–3.
Provide device‑specific speech perception thresholds (e.g., HINT, CNC, MLNT/LNT) per labeling.

Prior Authorization

Document implant laterality, age group, timing, and rehab potential

Prior authorization must document laterality (unilateral vs bilateral), patient age category (pediatric vs adult, ABI age ≥12), timing (simultaneous vs sequential bilateral implantation), and evidence the candidate can participate in postoperative auditory rehabilitation.

Specify whether implantation is unilateral, simultaneous bilateral, or sequential bilateral.
For pediatric cases, document timing considerations (evidence supports earlier implantation; children <37 months data cited).
Confirm plan for post‑implant rehabilitation participation.

Prior Authorization

Provide an evidence‑based, patient‑specific rationale

Prior authorization requests should include a patient‑specific evidence‑based rationale that addresses factors influencing expected benefit, such as age at implantation, duration and onset of deafness, preoperative hearing status, and any preserved acoustic hearing for hybrid devices.

Explain how age at implantation and duration of deafness affect expected outcomes.
For hybrid or SSD/AHL candidates, document preserved low‑frequency hearing or prior acoustic hearing use per device labeling.

Prior Authorization

Request prior authorization for unlisted or potentially covered services

Prior authorization is recommended for unlisted codes and for services that may be potentially covered but are billed with unlisted procedure codes; these submissions will be reviewed for medical necessity, coding accuracy, and pricing.

When no specific CPT/HCPCS code applies, submit prior authorization with full clinical documentation to avoid post‑service denial.
Unlisted codes are reviewed at claim level; non‑covered services billed with unlisted codes will be denied as not covered.

Billing Rule

Confirm PA requirements per updated billing/coding guidance

Confirm current prior authorization and review requirements against the updated billing and coding guidance, since billing tables were updated in 7/2023 and 11/2023.

Check the most recent billing/coding guidance and company prior authorization lists before submission.

Step Therapy

Document hearing‑aid trial and quantified limited benefit

Document a trial of appropriately fitted bilateral hearing aids and evidence of limited or no benefit before requesting implantation, except when a shorter trial is justified (e.g., cochlear ossification).

For children without prior aided experience, a three‑ to six‑month hearing‑aid trial is recommended (may be shortened if ossification is present).
Quantify limited benefit using device‑referenced speech perception measures or developmental progress measures (e.g., MAIS, ESP, MLNT/LNT).

Step Therapy

Expect a 3–6 month hearing‑aid trial prior to implantation when feasible

A hearing‑aid trial of approximately three to six months with appropriately fitted bilateral hearing aids is expected before implantation for candidates without prior aided experience, unless prior aided experience or cochlear ossification justifies a shorter trial.

Document duration of the hearing‑aid trial and measures of limited benefit (speech perception scores or lack of auditory progress).

Note

Document prior acoustic hearing use when requesting unilateral implants

When unilateral implantation is requested, document prior acoustic hearing use and rationale, since evidence supports the effectiveness and cost‑effectiveness of unilateral implants in adults and prior acoustic experience may influence expected benefit.

Include prior hearing‑aid usage history and duration of deafness to support expected outcomes for unilateral implantation.

Documentation Required

Attach device labeling and prior hearing‑aid/audiometry documentation

Include device‑specific FDA labeling and manufacturer details (as listed in Table 1–3) with the request and provide prior hearing‑aid trial records and relevant audiometry to demonstrate that device labeling criteria are met.

Attach Table 1–3 device labeling excerpts or cite manufacturer labeling showing age and audiologic criteria.
Provide prior hearing‑aid trial documentation and full audiometric test results.

Documentation Required

Submit preoperative audiology and hearing‑aid trial test results

Provide preoperative audiology documentation including pure‑tone thresholds (PTAs), speech perception test results (e.g., HINT, MLNT/LNT, CNC), and documented duration and outcomes of an appropriately fitted hearing‑aid trial to support limited benefit.

Include PTA values (e.g., adult PTA ≥70 dB at 500/1000/2000 Hz; pediatric thresholds as specified).
Include open‑set sentence or word recognition scores used to define limited benefit (device/age specific).

Documentation Required

Document clinical indications, laterality, duration/onset of deafness, and rehab plan

Provider documentation must state the clinical indications for implantation, planned laterality (unilateral vs bilateral), duration and onset of deafness, and the proposed auditory rehabilitation plan to demonstrate ability to achieve benefit.

Document duration of deafness and prior device use.
Describe expected rehabilitation program and patient/caregiver ability to participate.

Documentation Required

Supply key clinical documentation: age, laterality, prior hearing history

Key clinical details to include with requests are the patient's age at implantation, whether bilateral implantation is planned, prior hearing history and hearing‑aid trials, and expected functional benefit given variation by age and duration/onset of deafness.

State patient's age and developmental status (pediatric age cutoffs per policy).
Describe prior hearing history including length of hearing‑aid use and measured outcomes.

Billing Rule

Expect review of unlisted codes and submit PA for potentially covered unlisted services

All unlisted procedure codes submitted will be reviewed for medical necessity, accurate coding, and pricing at the claim level; prior authorization is recommended for unlisted codes for potentially covered services to avoid post‑service denial.

If no specific CPT/HCPCS code exists, include clinical justification and request prior authorization.
Note that unlisted codes billed for non‑covered services will be denied as not covered.

Documentation Required

Attach supporting references and literature citations

Include the literature citations and references used to support the medical necessity determination with the prior authorization request; references are available in the policy's references section.

Attach or cite key systematic reviews, RCTs, or device studies referenced in the policy to support the expected benefit.

Denial Risk

Risk of denial if medical necessity criteria are unmet

Requests that do not meet the policy's required medical necessity criteria will be denied as not medically necessary.

Ensure all required coverage criteria (relevant policy criteria groups) are documented in the prior authorization to avoid denial.

Denial Risk

Denial risk for missing hearing‑aid trial and quantified limited benefit

Failure to document a recommended three‑ to six‑month trial of appropriately fitted hearing aids for candidates without prior aided experience, or failure to quantify limited benefit (e.g., MLNT/LNT, HINT, CNC), may result in denial.

Provide trial duration and objective measures showing limited benefit to prevent denial for lack of step‑therapy documentation.

Denial Risk

Denial risk when evidence is insufficient for specific subgroups

There is insufficient evidence supporting bilateral cochlear implantation in certain populations (prelingually deafened adults or adults with significant non‑hearing disabilities); when these conditions are present, coverage may be denied.

If patient is a prelingually deafened adult or has significant disabilities other than hearing loss, provide robust individualized rationale or expect potential denial.

Denial Risk

Denial risk from insufficient or low‑quality supporting evidence

Limitations in the evidence base (small sample sizes, heterogeneity, lack of high‑quality randomized trials, and risk of bias) may lead to denials when submitted documentation does not demonstrate individualized expected benefit.

Provide stronger, patient‑specific outcome expectations when relying on limited or low‑quality evidence.

Billing Rule

Denied codes and common billing pitfalls to avoid

Billing with HCPCS L9900 for separate reimbursement will be denied, and HCPCS S2235 is not recognized for claim submission per company coding policy; use the appropriate CPT/HCPCS codes or add prior authorization for unlisted codes as instructed.

Do not bill HCPCS L9900 as separate reimbursement.
Do not use HCPCS S2235 for claim submission; use alternate CPT/HCPCS codes or an unlisted code with PA as needed.

Denial Risk

Denial classification updated — noncompliant requests will be NMN

Denials that were previously classified as investigational were reclassified to not medically necessary as of 8/2024; services not meeting the policy criteria will be denied as not medically necessary.

Expect denials for services that do not meet the current policy criteria; check revision history when planning submissions.

Definitions and Terms

Sensorineural hearing loss results from damage to the cochlea or auditory nerve pathways and can be congenital or acquired. Cochlear implants provide direct electrical stimulation of the auditory nerve via an implanted electrode array to restore auditory perception in appropriately selected patients; implantation requires surgical placement, device activation, and ongoing auditory rehabilitation.

inv-55: Sensorineural Hearing Loss (SNHL) — definition and causes

DefinitionSensorineural hearing loss (SNHL): hearing loss due to damage to the inner ear (cochlea) or nerve pathways from the inner ear to the brain

Common causesCauses include prolonged noise exposure, head trauma, congenital abnormalities, and infections (e.g., mumps, meningitis, otitis media)

Clinical characterizationTypically characterized as prelingual vs postlingual and unilateral vs bilateral depending on onset and laterality

inv-56: Hybrid cochlear implant — definition (short electrode + acoustic aid)

DefinitionHybrid cochlear implant: a shorter cochlear implant electrode array combined with external acoustic amplification (hearing aid) to preserve low-frequency hearing while restoring high-frequency perception

Intended useIntended for adults with severe-to-profound high-frequency SNHL and residual low-frequency hearing

Risk noteHybrid devices carry a substantial risk of loss of residual hearing; evidence quality is limited

inv-57: Single-sided deafness (SSD) — definition

DefinitionSingle-sided deafness (SSD): profound sensorineural hearing loss in one ear with normal hearing or mild SNHL in the contralateral ear

Policy contextPolicy notes cochlear implantation for SSD in selected individuals (device labeling and evidence summaries reference SSD indications)

Outcomes noteSystematic reviews report improvements in speech perception, localization, and tinnitus in SSD patients though studies are heterogeneous and often small

inv-58: Asymmetric hearing loss (AHL) — definition

DefinitionAsymmetric hearing loss (AHL): profound SNHL in one ear and mild to moderately severe SNHL in the other ear with a difference of at least 15 dB in pure tone averages between ears

Policy useAHL criteria are used in device labeling and candidate selection for certain cochlear implant indications

inv-59: Simultaneous vs sequential bilateral implantation — definition and operative timing

Simultaneous implantationSimultaneous bilateral implantation: both implants placed in a single operative setting

Sequential implantationSequential bilateral implantation: second implant placed at a later time; some pediatric studies report benefits when the interval between implants is short

Clinical relevanceTiming (simultaneous vs sequential) influences rehabilitation timing and may affect outcomes such as localization and language development

inv-60: Duration of deafness — definition and relevance to outcomes

DefinitionDuration of deafness: time elapsed from onset of deafness to implantation

RelevanceLonger duration of deafness is associated with reduced implant effectiveness for speech perception and quality of life; implants placed in the ear with shorter deafness duration have better outcomes

Clinical implicationDocumenting duration of deafness is important for prior authorization and expected rehabilitation potential

inv-61: Hybrid cochlear implant (alternate) — combined acoustic amplification and electrical stimulation intended population

Definition / populationHybrid cochlear implant (alternate): combined acoustic amplification (low frequencies) and electrical stimulation (high frequencies) intended for adults with severe-to-profound high-frequency SNHL and preserved low-frequency hearing

Device labeling detailsFDA-labeled hybrid device criteria include specific PTA and CNC word recognition score ranges and low-frequency threshold limits (see device labeling)

Evidence cautionHybrid implants may preserve residual hearing but evidence is low-quality and long-term outcomes are uncertain

inv-62: SSD / UHL — single-sided deafness / unilateral hearing loss defined

DefinitionSSD / UHL: single-sided deafness (unilateral hearing loss) defined as significant or profound hearing loss in one ear while the contralateral ear has normal or near-normal hearing

Policy considerationCochlear implantation for SSD/UHL can improve speech perception, localization, and tinnitus in selected patients per device labeling and evidence summaries

inv-63: Auditory brainstem implant (ABI) — definition and typical indications

DefinitionAuditory brainstem implant (ABI): implant electrodes placed on the cochlear nucleus of the brainstem to bypass a nonfunctional cochlear nerve and provide auditory stimulation

Typical indicationsTypically indicated for patients with Neurofibromatosis Type 2 (NF2) who have no functional auditory nerve or who will lose nerve function during tumor resection

Outcome expectationsABIs offer limited hearing rehabilitation (improved sound awareness, lip-reading–aided communication); sentence and word perception often improved when combined with lip reading

inv-64: Severe to profound bilateral sensorineural hearing loss — definition and referencing professional society/FDA indications

DefinitionSevere to profound bilateral SNHL: clinical condition meeting professional society and FDA indications for cochlear implantation (e.g., PTA and frequency-specific thresholds meeting device labeling)

Guideline referencesReferenced in AAA, AAO-HNS, NICE, and AAP guidance as the population for which cochlear implants are indicated

Policy relevancePolicy aligns coverage with FDA-approved indications and professional society guidance for this population

inv-65: Auditory brainstem implant — restated definition/use cases

Definition / use casesAuditory brainstem implant: neuroprosthetic device placed on the cochlear nucleus used to restore some hearing function in patients without a functional cochlear nerve (e.g., NF2); used when cochlear implantation is not feasible

Clinical contextABIs are typically implanted by experienced surgical teams with governance and are supported by limited evidence showing improved sound/environmental differentiation

inv-66: Auditory brainstem implant (ABI) — additional ABI definition entry

ABI definition (additional)Auditory brainstem implant (ABI): implantable device that provides auditory stimulation when cochlear implantation is not feasible due to absent or nonfunctional auditory nerve; often used in NF2 and select non-NF2 cases

Evidence characteristicsEvidence comprises systematic reviews and small nonrandomized studies; ABI outcomes often include better speech perception with lip reading and improved sound awareness

Age considerationsABI use in adolescents and adults is described; referenced studies include procedures in 12- to 18-year-olds in select series

Background and Evidence Summary

Cochlear implants and auditory brainstem implants are used in clinical contexts where acoustic amplification is insufficient. ABIs bypass the cochlea and stimulate the cochlear nucleus and are indicated for patients (e.g., Neurofibromatosis Type 2) with nonfunctional auditory nerves. Both device types require candidate selection based on imaging, audiometric thresholds, documented limited benefit from appropriately fitted hearing aids, and the ability to participate in post-implant rehabilitation.

inv-08: Coverage evidence nodes for unilateral and bilateral cochlear implants

Evidence-supported coverage considerations derived from reviews and trials

Adults - Bilateral CI benefit: Bilateral cochlear implants improve sound localization and speech perception in noise compared with unilateral implants; clinical trials and systematic reviews support benefit for postlingual severe-to-profound bilateral sensorineural hearing loss in adults who can undergo auditory rehabilitation.

Hayes B rating and multiple systematic reviews report benefit

Adults - Limited evidence: Insufficient evidence for bilateral CI efficacy in prelingually deafened adults, adults with only moderate deafness, or adults with significant disabilities other than hearing loss.

Hayes D2 rating

Adults - Unilateral CI: Unilateral cochlear implants provide significant benefit over hearing aids or non-technological support for adults with severe-to-profound sensorineural hearing loss and appear cost-effective in identified studies.

Systematic reviews and RCTs show improved outcomes; duration of deafness impacts outcomes

Prospective and retrospective studies indicate advantages with earlier implantation

Pediatrics - Bilateral CI: Bilateral cochlear implantation in children improves sound localization and hearing in noise over unilateral implants; evidence suggests benefits for preverbal communication and turn-taking behaviors though randomized trials are limited.

Systematic reviews and observational studies support localization and some language-related benefits

inv-09: Evidence-based coverage observations

Summaries of when benefit is most consistently observed (evidence-based observations):

Bilateral implantation benefits: Bilateral cochlear implantation in children is associated with improved localization, preverbal communication and turn-taking behaviors compared with unilateral implants; earlier acoustic experience and earlier implantation (<12 months) are associated with better outcomes.

Supported by observational and retrospective studies

Cochlear implants for SSD/UHL: Systematic reviews and meta-analyses report improvements in speech perception, localization, tinnitus suppression, and quality of life for single-sided deafness (SSD) or asymmetric hearing loss (AHL), but evidence is limited by small sample sizes, heterogeneity, and risk of bias; shorter duration of deafness and acquired SSD are associated with better outcomes.

Supported by multiple systematic reviews and meta-analyses

Auditory brainstem implant utility: ABIs offer limited hearing rehabilitation for patients without a functional cochlear nerve (e.g., NF2), improving detection of environmental sounds and lip-reading–aided perception; outcomes may improve over years but are generally more limited than cochlear implants.

Cochlear Implants and Auditory Brainstem Implants

Sign up for Providence Health Plan Policy 127 alerts

Coverage Criteria for Cochlear and Auditory Brainstem Implants

Billing and Coding

Prior Authorization, Documentation, and Provider Requirements

Definitions and Terms

Background and Evidence Summary

Revision History