CurrentUnitedHealthcarePolicy CSO19KS.02

Cochlear Implants (for Kansas Only)

This policy governs medical necessity and coverage considerations for cochlear implantation (including non-hybrid and hybrid devices) for UnitedHealthcare members in Kansas, specifying age-based criteria and referencing InterQual criteria and state benefit rules.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for Kansas Only)

Policy CodePolicy CSO19KS.02

Change TypeSupporting information and references updatedarchived prior version

Effective Date09/01/2025

Next Review DateN/A

Key ActionSubmit prior authorization documentation showing InterQual medical necessity criteria are met and reference applicable state/benefit rules.

SourceLink

POLICY UPDATE CHANGES

Supporting Information Updated References section to reflect the most current information; Archived previous policy version CSO19KS.01

09/01/2025effective date

KS onlystate-specific

69930, L8614-L8628, V5273codes referenced

InterQualprimary criteria

Coverage and Medical Necessity Criteria

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Medical Necessity Criteria (summary tied to InterQual)

Coverage is tied to InterQual clinical criteria; summarized age-based indications in the policy:

Non-hybrid cochlear implantation in adults: Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral and/or single-sided or asymmetric sensorineural hearing loss in adults ages 18 and older; refer to InterQual for clinical coverage criteria.age >= 18

See InterQual CP: Procedures, Cochlear Implantation for specific numeric/functional thresholds

Non-hybrid cochlear implantation in children: Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral sensorineural hearing loss in children ages 6 months or older and for single-sided or asymmetric sensorineural hearing loss in children ages 9 months or older; refer to InterQual Pediatric CP: Procedures, Cochlear Implantation.age >= 6 months for bilateral; age >= 9 months for single-sided/asymmetric

InterQual Pediatric CP referenced

Non-covered (experimental) pediatric scenarios: 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 or investigational due to lack of FDA approval.age < 6 months bilateral; age < 9 months single-sided/asymmetric

Policy cites lack of FDA approval

Hybrid cochlear implantation in adults: Hybrid cochlear implantation is proven and medically necessary under certain circumstances for sensorineural hearing loss in adults ages 18 and older; refer to InterQual for clinical coverage criteria.age >= 18

See InterQual for details

This policy ties coverage for cochlear implantation to InterQual clinical criteria. For non-hybrid cochlear implants, adults (age 18 and older) may be considered for implantation for bilateral, single-sided, or asymmetric sensorineural hearing loss when InterQual criteria are met. In pediatric patients, non-hybrid cochlear implantation is considered medically necessary for bilateral sensorineural hearing loss in children aged 6 months or older and for single-sided or asymmetric sensorineural hearing loss in children aged 9 months or older, per the InterQual pediatric criteria. Conversely, non-hybrid cochlear implantation in children younger than 6 months for bilateral loss or younger than 9 months for single-sided/asymmetric loss is identified as experimental or investigational due to lack of FDA approval.

For pediatric-specific application, the policy explicitly notes that implantation in children younger than 6 months for bilateral sensorineural hearing loss and younger than 9 months for single-sided or asymmetric sensorineural hearing loss is considered experimental or investigational because of the absence of FDA approval. Providers submitting prior authorization or clinical documentation for pediatric cochlear implantation should reference the InterQual pediatric coverage criteria to demonstrate that age and clinical thresholds are satisfied before coverage is approved.

Procedure and Supply Codes

Applicable procedure and supply codesmixed

69930	Cochlear device implantation, with or without mastoidectomy.
L8614
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

Prior Authorization, Documentation, and Denial Guidance

Prior Authorization

Prior authorization tied to InterQual criteria

Cochlear implantation and associated external processor replacements are reviewed against InterQual medical necessity criteria; prior authorization is implied by the requirement to meet InterQual criteria and applicable federal, state, or contractual benefit rules.

Applicable CPT/HCPCS codes to review include 69930, L8614-L8619, L8627-L8628, V5273 as listed in the policy.

Step Therapy

Step therapy — none specified

No explicit step therapy requirements are stated in this policy; UnitedHealthcare uses InterQual as the primary medical/surgical criteria when assessing cochlear implantation requests.

Documentation Required

Documentation to support InterQual criteria

Providers must submit clinical documentation sufficient to demonstrate that the InterQual clinical coverage criteria for cochlear implantation are met and reference applicable federal, state, or contractual benefit terms when requesting coverage.

Include clinical information that addresses the InterQual CP: Procedures, Cochlear Implantation (pediatric or adult) as applicable.
Reference federal, state, or contractual requirements when submitting for coverage (e.g., Kansas Medical Assistance Program manual).

Denial Risk

Denial risk when InterQual criteria not met

Procedures that do not meet the InterQual cochlear implantation criteria (for example, age- or function-based thresholds defined in InterQual) may be considered not medically necessary and could be denied.

Pediatric implants performed below the InterQual/age thresholds noted in the policy risk denial (see pediatric age thresholds).

Denial Risk

Denial risk for benefit misclassification

Services billed under the incorrect benefit (for example, placing items that should be adjudicated under DME vs medical-surgical) or that are inconsistent with Kansas Medical Assistance Program requirements may be denied.

Verify whether implantable components are adjudicated under the medical-surgical benefit and external processors under DME per the policy and state manuals.
Check federal, state, or contractual requirements (Kansas Medical Assistance Program) before billing.

OpenPayer

Cochlear Implants (for Kansas Only)

Coverage and Medical Necessity Criteria

Procedure and Supply Codes

Prior Authorization, Documentation, and Denial Guidance

Clinical Background

Key Terms

Policy Revision History