CurrentUnitedHealthcarePolicy CS019OH.D

Cochlear Implants (for Ohio Only)

UnitedHealthcare medical policy governing coverage determinations for cochlear implants (non-hybrid and hybrid) for members in Ohio; references InterQual clinical criteria for specific medical necessity details and applies Ohio Administrative Code where services are unproven or limited.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for Ohio Only)

Policy CodePolicy CS019OH.D

Change TypeDocumentation & supporting information updates

Effective DateDec 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record contains legible documentation that fully supports medical necessity (relevant history, physical exam, and pertinent diagnostic test results) and make it available upon request.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria.

Updated Supporting Information, Clinical Evidence and References sections to reflect current information.

Adults >=18Covered Indication (non-hybrid & hybrid when InterQual met)

Children >=6 monthsCovered when InterQual pediatric criteria met

Children <6 monthsNot Covered (non-hybrid) - experimental/investigational

Coverage Summary

Scope: UnitedHealthcare medical policy CS019OH.D governing coverage determinations for cochlear implants (hybrid and non-hybrid) for members in Ohio only. Subject: Cochlear Implants (non-hybrid and hybrid). Payer: UnitedHealthcare (Ohio-specific policy). Policy number: CS019OH.D. Effective / Last review date: Effective December 1, 2025; Last review December 1, 2025. Coverage stance summary: Mixed — some cochlear implant indications are considered proven/medically necessary when InterQual criteria and applicable federal/state/contractual requirements are met (e.g., adults and some pediatric groups), while other uses (children <6 months) are considered experimental/investigational. Geographic restriction: Applies only to Ohio members.

Key coverage statistics

Covered Indication (non-hybrid & hybrid when InterQual met)Adults >=18

Not Covered (non-hybrid) - experimental/investigationalChildren <6 months

Covered when InterQual pediatric criteria metChildren >=6 months

Provider Actions & Requirements

Documentation Required

Medical record documentation requirement

Medical record documentation must fully support the medical necessity for the requested cochlear implant services. Documentation may be requested to assess whether the member meets clinical criteria but does not guarantee coverage. Medical records should be legible, maintained in the member's chart, and made available upon request.

Relevant medical history (hearing loss history, prior treatments, hearing aid use and benefit)
Findings from physical examination (otologic exam, neurologic exam as appropriate)
Results of pertinent diagnostic tests or procedures (audiometric test results, aided and unaided speech recognition scores, imaging studies such as CT or MRI when required)

Prior Authorization

Prior authorization / medical necessity review

Prior authorization and medical necessity review are required for cochlear implantation requests. Use the InterQual® CP: Procedures, Cochlear Implantation criteria for the primary medical necessity determination. If InterQual does not have applicable criteria for the specific clinical situation, UnitedHealthcare will apply Ohio- approved UnitedHealthcare Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines as applicable.

Reference InterQual® CP: Procedures, Cochlear Implantation (adult and pediatric as applicable) for clinical coverage criteria
If InterQual criteria do not apply, reference UnitedHealthcare/Ohio policies and guidelines that have been approved by the Ohio Department of Medicaid Services
Ensure prior authorization submission includes the required medical record documentation listed above

Coding

CPT / Procedure Codes (reference)CPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS / Supply and Accessory Codes (reference)HCPCS

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 and controller, integrated system, replacement.
L8627	Cochlear implant, external speech processor, component, replacement.
L8628	Cochlear implant, external controller component, replacement.
V5273	Assistive listening device, for use with cochlear implant

Background & Definitions

Background: This policy applies only to the state of Ohio and uses InterQual CP: Procedures, Cochlear Implantation (adult and pediatric as applicable) as the primary source for medical necessity determinations. Hybrid and non-hybrid cochlear implants are considered proven and medically necessary in certain adult circumstances and for some pediatric indications when InterQual criteria are met. Implants for children younger than 6 months are considered experimental or investigational because they lack FDA approval. Regulatory note: FDA Premarket Approval information for non-hybrid (product code MCM) and hybrid (product code PGQ) cochlear implants is referenced for informational purposes only and does not by itself establish coverage.

Definitions: Sensorineural Hearing Loss (SNHL) — Occurs when there is damage to the inner ear (cochlea), or to the nerve pathways from the inner ear to the brain; most SNHL cannot be medically or surgically corrected and is the most common type of permanent hearing loss.

Revision History

2025-12-01material_changeLatest

Added explicit documentation expectations: benefit coverage is determined by federal, state (OAC), or contractual requirements and applicable laws; medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; patient's medical record must fully support medical necessity (relevant history, physical exam, pertinent diagnostic test/procedure results), be legible, maintained, and made available upon request.

2025-12-01archival_revision

Archived previous policy version CS019OH.C and updated Supporting Information, Clinical Evidence, and References sections to reflect current information.