CurrentUnitedHealthcarePolicy CS019NJ.Q

Cochlear Implants (for New Jersey Only)

Medical policy governing coverage and medical necessity criteria for cochlear implants for members of UnitedHealthcare Community Plan in New Jersey.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for New Jersey Only)

Policy CodePolicy CS019NJ.Q

Change TypeNo material changes

Effective DateSep 1, 2025

Next Review Date

Key ActionUse InterQual CP: Procedures, Cochlear Implantation to support medical necessity determinations and prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

State-specificjurisdiction

Adults ≥18adult eligibility

Children ≥6 monthspediatric bilateral age

Children <6 or <9 monthspediatric younger

InterQual referencedclinical criteria

Coverage and Medical Necessity Criteria

Medical Necessity Criteria (refer to InterQual)

Covered when ALL of the following InterQual-based and age-specific conditions are met:

Adults - non-hybrid: Non-hybrid cochlear implantation is medically necessary under certain circumstances for bilateral and/or single-sided or asymmetric sensorineural hearing loss in adults.age >= 18

Use InterQual CP: Procedures, Cochlear Implantation for clinical coverage criteria.

Pediatric - bilateral non-hybrid: Non-hybrid cochlear implantation is medically necessary under certain circumstances for bilateral sensorineural hearing loss in children.age >= 6 months

Children younger than 6 months: procedure is experimental/investigational due to lack of FDA approval; refer to InterQual Pediatric criteria.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for New Jersey Only)

Policy CodePolicy CS019NJ.Q

Change TypeNo material changes

Effective DateSep 1, 2025

Next Review Date

Key ActionUse InterQual CP: Procedures, Cochlear Implantation to support medical necessity determinations and prior authorization requests.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Non-hybrid cochlear implantation is recognized as medically necessary under defined conditions for both adults and children. For adults, non-hybrid and hybrid cochlear implantation are considered when InterQual CP: Procedures, Cochlear Implantation criteria are met; adults are evaluated using the InterQual adult criteria (refer to InterQual for full clinical coverage rules).

For pediatric patients, non-hybrid cochlear implantation may be medically necessary for bilateral sensorineural hearing loss (SNHL) in children aged 6 months or older, and for single-sided or asymmetric SNHL in children aged 9 months or older. Providers should apply the pediatric InterQual CP: Procedures, Cochlear Implantation criteria when documenting medical necessity and submitting prior authorization requests.

Non-hybrid cochlear implantation in children younger than the stated FDA-based age thresholds is considered experimental/investigational and therefore not medically established. Specifically, implantation for bilateral SNHL in children younger than 6 months and for single-sided or asymmetric SNHL in children younger than 9 months is experimental or investigational due to lack of Food and Drug Administration (FDA) approval.

When treating pediatric patients near these age cutoffs, providers must reference the policy and InterQual pediatric criteria and document FDA-approval status and clinical rationale; implantation performed below these thresholds will generally be categorized as not medically necessary/experimental.

Procedure and Supply Codes

Procedure CPTCPTCovered

69930

Cochlear device implantation, with or without mastoidectomy.

DME HCPCS/L-codesHCPCSCovered

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.

Other HCPCSHCPCS

V5273

Assistive listening device, for use with cochlear implant

Provider Responsibilities and Billing Rules

Prior Authorization

Prior Authorization Required

InterQual is required for medical necessity determinations and prior authorization decisions for cochlear implantation. Providers must refer to the InterQual CP: Procedures, Cochlear Implantation (adult and pediatric versions as applicable) when submitting requests for coverage or prior authorization.

InterQual CP: Procedures, Cochlear Implantation (adult) — used for medical necessity and prior authorization determinations.
InterQual CP: Procedures, Cochlear Implantation (Pediatric) — used for medical necessity and prior authorization determinations for pediatric patients.
Link to InterQual criteria is available on the UnitedHealthcare provider site.

Billing Rule

Coding Inclusion Does Not Guarantee Coverage

Coding lists in this policy are for reference only; inclusion of a code does not guarantee coverage or payment. Providers should not assume reimbursement solely because a code appears in this policy.

The policy’s code list is not all-inclusive and does not imply that services are covered.
Codes marked with an asterisk (*) are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by NJ Medicaid.

Billing Rule

Benefit Assignment and Billing Implications

Benefit assignment for cochlear implant components varies: external components (speech processor, microphone, transmitter coil) are handled under the DME benefit, while implantable components are handled under the medical-surgical benefit. Check applicable federal, state, or contractual requirements for exact benefit determination and billing instructions.

External components (e.g., speech processor, microphone, transmitter coil) — DME benefit.
Implantable components — medical-surgical benefit.
Refer to the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for New Jersey Only) policy for billing guidance.

Documentation Required

Check Governing Benefit Terms

Providers must check governing federal, state, and contractual benefit terms before relying on this policy. In the event of a conflict, the federal, state, or contractual requirements govern. This policy is informational and does not replace checking specific plan terms.

Verify coverage against the member’s federal/state/contractual plan documents prior to submitting claims or prior authorization requests.
UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administration; these tools inform but do not replace plan-specific terms.

Clinical Background

Sensorineural hearing loss (SNHL) results from damage to the inner ear (cochlea) or the nerve pathways from the inner ear to the brain and is typically permanent. Cochlear implants provide an electrical stimulation of the auditory nerve to improve hearing function when conventional amplification is insufficient.

Cochlear implantation (non-hybrid and hybrid) is used to restore access to sound for individuals with significant SNHL who meet clinical criteria. This policy relies on InterQual CP: Procedures, Cochlear Implantation to establish the medical necessity criteria and includes pediatric age cutoffs and FDA considerations that affect coverage decisions.

OpenPayer

Cochlear Implants (for New Jersey Only)

Coverage and Medical Necessity Criteria

Procedure and Supply Codes

Provider Responsibilities and Billing Rules

Clinical Background

Key Definitions