CurrentUnitedHealthcarePolicy CS019NM.D

Cochlear Implants (for New Mexico Only)

UnitedHealthcare medical policy for cochlear implants applicable only to New Mexico members. Defines coverage stance for non-hybrid and hybrid cochlear implantation by age and refers to InterQual CP criteria for specific medical necessity clinical criteria; includes coding, benefit considerations, documentation requirements, and FDA informational links.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for New Mexico Only)

Policy CodePolicy CS019NM.D

Change TypeDocumentation requirement added

Effective DateJune 1, 2026

Next Review Date

Key ActionEnsure medical records fully document medical necessity (history, exam, and diagnostic test results), are legible, maintained, and available upon request.

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements for reviews and that benefit coverage is determined by federal, state, or contractual requirements.

Archived previous policy version CS019NM.C.

Adults ≥18Non-hybrid covered age (adults)

Children ≥6mNon-hybrid bilateral SNHL covered (pediatric)

Children ≥9mNon-hybrid single-sided/asymmetric SNHL covered (pediatric)

Children <6mNon-hybrid bilateral SNHL not covered

Coverage Summary

UnitedHealthcare medical policy for cochlear implants applicable only to New Mexico members. The policy defines coverage for non-hybrid and hybrid cochlear implantation with a mixed coverage stance: certain non-hybrid and hybrid indications are covered for adults and certain pediatric age groups, while other pediatric ages/indications are considered experimental/investigational.

The policy directs that specific medical necessity clinical coverage criteria are determined using the InterQual® CP: Procedures, Cochlear Implantation (adult and pediatric as applicable) and requires that members meet those InterQual criteria for coverage decisions.

Benefit determination is split: external cochlear implant components (speech processor, microphone, transmitter coil) are considered under the DME benefit, while implantable components are considered under the medical-surgical benefit (verify federal, state, or contractual plan for final determination).

FDA approval information for non-hybrid and hybrid cochlear implants is provided for informational purposes only and is not by itself a basis for coverage.

Coverage age thresholds

Non-hybrid covered (Adults)Adults ≥18

Non-hybrid covered (Pediatric bilateral)Children ≥6 months

Non-hybrid covered (Pediatric single-sided/asymmetric)Children ≥9 months

Non-hybrid not covered (Pediatric bilateral)Children <6 months

Non-hybrid not covered (Pediatric single-sided/asymmetric)Children <9 months

Medical Necessity Criteria (InterQual-referenced)

Non-hybrid cochlear implantation - Adults

Covered when ALL of the following are met:

ALL of the following

Patient is an adult age 18 years or older
Indication: bilateral sensorineural hearing loss and/or single-sided or asymmetric sensorineural hearing loss
Meets medical necessity clinical coverage criteria as defined by InterQual CP: Procedures, Cochlear Implantation (adult)

Non-hybrid cochlear implantation - Pediatrics (covered ages)

Covered when ALL of the following are met:

ALL of the following

Not Covered / Experimental Criteria

Non-hybrid cochlear implantation - Pediatrics (not covered ages)

Considered experimental/investigational when any of the following apply:

ANY of the following

Patient is a child younger than 6 months and the indication is bilateral sensorineural hearing loss
Patient is a child younger than 9 months and the indication is single-sided or asymmetric sensorineural hearing loss
Lack of FDA approval for implantation in those younger age groups

Hybrid cochlear implantation - Pediatrics (not covered)

Considered experimental/investigational when:

ANY of the following

Coding

Procedure CPTCPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS - Implantable and external device 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 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.

Provider Actions & Billing Notes

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request.

Relevant medical history
Physical examination
Results of pertinent diagnostic tests or procedures
Documentation must be legible
Documentation must be maintained in the patient's medical record
Documentation must be made available upon request

Background

Policy applies only to New Mexico. UnitedHealthcare uses InterQual® CP criteria to determine medical necessity for cochlear implantation; providers should reference InterQual criteria when requesting authorization.

External cochlear implant components (speech processor, microphone, and transmitter coil) are considered under the DME benefit, while implantable components are considered under the medical-surgical benefit; check federal, state, or contractual requirements for benefit coverage.

Medical records must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation should be legible, maintained in the patient's medical record, and made available upon request.

FDA approval information for non-hybrid and hybrid cochlear implants is included for reference only; FDA approval alone is not a basis for coverage.

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.

Revision History

06/01/2026material_changeLatest

Added language clarifying medical records documentation requirements for reviews and that benefit coverage is determined by federal, state, or contractual requirements. Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; must be legible, maintained in the patient's medical record, and made available upon request.

archival

Archived previous policy version CS019NM.C.