CurrentUnitedHealthcarePolicy CS019.S

Cochlear Implants

Policy governs medical necessity, coverage considerations, and coding for cochlear implants (including hybrid and non-hybrid) for UnitedHealthcare members; it specifies age groups, indications, and references use of InterQual criteria and state-specific exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants

Policy CodePolicy CS019.S

Change TypeMinor editorial/state applicability updates

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain and document required medical records and confirm InterQual medical necessity criteria prior to requesting prior authorization.

SourceLink

POLICY UPDATE CHANGES

Application Nebraska Added language to indicate this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.

Medical Records Documentation Used for Reviews: Added language indicating that benefit coverage is determined by federal, state, or contractual requirements and that documentation may be required but does not guarantee coverage.

CS019.SPolicy identifier

Adults ≥18; Children ≥6moCovered age groups

Children <6mo / <9mo (single-sided)Experimental groups

69930, L8614-L8628, V5273Example codes listed

Exceptions included

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants

Policy CodePolicy CS019.S

Change TypeMinor editorial/state applicability updates

Effective DateSep 1, 2025

Next Review Date

Key ActionObtain and document required medical records and confirm InterQual medical necessity criteria prior to requesting prior authorization.

SourceLink

On This Page

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Coverage Criteria for Cochlear Implants

Medical Necessity and Age-based Coverage

Covered when ALL of the following are met as defined by InterQual clinical criteria:

InterQual compliance: Patient meets the InterQual CP: Procedures, Cochlear Implantation clinical coverage criteria for cochlear implantation (non-hybrid or hybrid as applicable)

Age and indication (non-hybrid): Non-hybrid cochlear implantation is medically necessary for adults 18 years and older for bilateral sensorineural hearing loss and/or single-sided or asymmetric sensorineural hearing loss; non-hybrid cochlear implantation is medically necessary for children 6 months of age and older for bilateral sensorineural hearing loss and for single-sided or asymmetric sensorineural hearing loss

Hybrid cochlear implantation (adults): Hybrid cochlear implantation is medically necessary under certain circumstances for adults ages 18 and older (refer to InterQual criteria)

FDA and age restrictions (pediatric experimental): Non-hybrid cochlear implantation for bilateral sensorineural hearing loss in children younger than 6 months and for single-sided or asymmetric sensorineural hearing loss in children younger than 9 months is considered experimental/investigational due to lack of FDA approval

Non-hybrid cochlear implantation coverage is determined by clinical criteria as defined in the InterQual CP: Procedures, Cochlear Implantation. For non-hybrid devices, coverage depends on meeting those InterQual clinical criteria and the age- and laterality-specific indications noted in this policy. Specifically, non-hybrid cochlear implantation is recognized as medically necessary for appropriate adults (age 18 years and older) for bilateral sensorineural hearing loss (SNHL) and for single-sided or asymmetric SNHL when InterQual criteria are met. For pediatric patients, non-hybrid cochlear implantation is medically necessary for children age 6 months and older for bilateral SNHL and for single-sided or asymmetric SNHL when the InterQual coverage criteria are satisfied.

Non-hybrid cochlear implantation for bilateral SNHL in children younger than 6 months and for single-sided or asymmetric SNHL in children younger than 9 months is considered experimental or investigational due to lack of Food and Drug Administration (FDA) approval. Use of cochlear implantation in these specified pediatric age groups is therefore considered not medically necessary/experimental and is excluded from coverage under this policy.

Procedure and Supply Codes

Covered CPT Codes (reference list)CPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS Codes (external components and replacements)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
L8628	Cochlear implant, external controller component, replacement.

HCPCS (assistive listening)HCPCS

V5273

Assistive listening device, for use with cochlear implant

Provider Requirements and Benefit Alignment

Prior Authorization

InterQual-based medical necessity / prior authorization

Coverage of cochlear implantation (including non-hybrid and pediatric indications) is contingent on meeting InterQual medical necessity criteria. Prior authorization may be required; refer to the InterQual CP: Procedures, Cochlear Implantation for specific clinical criteria.

See InterQual medical necessity criteria for adults and children
Prior authorization requirements per payer guidelines

Note

Benefit alignment for external components

External cochlear implant components (for example: speech processor, microphone, transmitter coil) are covered under the Durable Medical Equipment (DME) benefit; implantable components are covered under the medical-surgical benefit. Check federal, state, or contractual requirements for plan-specific benefit alignment and refer to the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy for coverage details.

External components billed under DME benefit (speech processor, microphone, transmitter coil)

Background and Clinical Context

Sensorineural hearing loss (SNHL) results from damage to the cochlea or auditory nerve pathways and is commonly permanent. Cochlear implants, including both hybrid and non-hybrid systems, provide auditory access for selected patients with SNHL who meet established clinical criteria. This policy relies on the InterQual CP: Procedures, Cochlear Implantation to define medical necessity for cochlear implantation; hybrid implantation is described as proven and medically necessary under certain circumstances for adults age 18 and older, whereas certain pediatric non-hybrid indications are restricted due to FDA approval limits.

Definitions

Sensorineural Hearing Loss (SNHL) — Definition and notes

DefinitionSensorineural 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.

Typical permanenceMost of the time, SNHL cannot be medically or surgically corrected and is the most common type of permanent hearing loss.

Anatomic sourcesDamage may involve the cochlea (inner ear) or the auditory nerve pathways to the brain.

Clinical implicationSNHL often underlies indications for cochlear implantation when amplification is insufficient to provide functional hearing.

AuthorityDefinition sourced from American Speech-Language-Hearing Association (ASHA) wording in the policy document.