CurrentUnitedHealthcarePolicy CS019NM.C

Cochlear Implants (for New Mexico Only)

This policy governs medical necessity and coverage considerations for cochlear implantation (including non-hybrid and hybrid devices and external components) for UnitedHealthcare members in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for New Mexico Only)

Policy CodePolicy CS019NM.C

Change TypeRoutine review — no material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization that aligns with InterQual CP: Procedures, Cochlear Implantation to establish medical necessity.

SourceLink

POLICY UPDATE CHANGES

09/01/2025 routine review; no change to coverage guidelines; archived previous policy version CS019NM.B

NMgeographic application

Adults ≥18adult coverage

≥6 mopediatric bilateral

≥9 mopediatric single-sided

<6/9 mopediatric experimental

External = DMEbenefit partitioning

Coverage Criteria

Adult non-hybrid cochlear implantation

Non-hybrid cochlear implantation coverage (adults):

Adult non-hybrid cochlear implantation: Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral sensorineural and/or for single-sided or asymmetric Sensorineural Hearing Loss in adults.age >= 18

Clinical coverage criteria are defined by InterQual CP: Procedures, Cochlear Implantation (adult).

Pediatric non-hybrid cochlear implantation

Pediatric non-hybrid cochlear implantation coverage:

Pediatric non-hybrid cochlear implantation - bilateral: Proven and medically necessary for bilateral Sensorineural Hearing Loss in children ages 6 months or older.age >= 6 months

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for New Mexico Only)

Policy CodePolicy CS019NM.C

Change TypeRoutine review — no material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization that aligns with InterQual CP: Procedures, Cochlear Implantation to establish medical necessity.

SourceLink

On This Page

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Pediatric age exclusions

Pediatric non-hybrid cochlear implantation exclusions based on age:

Pediatric too young - experimental/investigational: 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 experimental or investigational due to lack of FDA approval.age < 6 months or age < 9 months depending on indication

May be denied as not medically necessary/experimental; see FDA approvals for details.

For pediatric cochlear implantation, there are specific age-based considerations that affect coverage. Non-hybrid cochlear implantation is deemed proven and medically necessary for bilateral sensorineural hearing loss (SNHL) in children ages 6 months or older and for single-sided or asymmetric SNHL in children ages 9 months or older. Clinical eligibility details and required clinical documentation should follow the InterQual CP: Procedures, Cochlear Implantation (Pediatric).

When requesting authorization or submitting claims for pediatric cases, cross-reference the InterQual pediatric cochlear implantation criteria to establish medical necessity and ensure the member meets the applicable minimum age thresholds. Cases that do not meet the age thresholds below should be carefully reviewed against FDA approvals and the InterQual criteria before proceeding.

Coding and Age Thresholds

Covered CPT Codes (reference list)CPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS Codes (external/internal device components)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

Pediatric minimum ages for non-hybrid implantation

Bilateral non-hybrid cochlear implantation (pediatric)Minimum age: 6 months

Single-sided or asymmetric non-hybrid cochlear implantation (pediatric)Minimum age: 9 months

Under‑minimum‑age policy stanceImplantation below the specified minimum ages is considered experimental/investigational and may be denied

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Required

InterQual-based prior authorization is required for cochlear implantation procedures. Refer to the InterQual CP: Procedures, Cochlear Implantation (adult and pediatric sets) when submitting prior authorization requests to ensure clinical criteria are met.

Prior authorization must reference the applicable InterQual procedure set.
Links to InterQual: https://www.uhcprovider.com/content/provider/en/policies-protocols/sec_interqual-clinical-criteria.html

Denial Risk

Age-Based Experimental/Investigational Denial Risk

There is a documented age-based denial risk for cochlear implantation: non-hybrid cochlear implantation is medically necessary in adults ages 18 and older and in children ages 6 months or older for bilateral loss (and ages 9 months or older for single-sided/asymmetric loss). Implantation in children younger than these minimum ages is considered experimental/investigational and may be denied.

Adults: 18 years and older for non-hybrid and hybrid cochlear implants.
Pediatric bilateral SNHL: 6 months and older.
Pediatric single-sided/asymmetric SNHL: 9 months and older.
Children younger than the specified minimum ages — considered experimental/investigational; likely denial.

Documentation Required

Benefit Partitioning and Coding Documentation

Document benefit partitioning and coding for implantable versus external components: implantable components are billed to the medical-surgical benefit; external components (speech processor, microphone, transmitter coil) are billed to the DME benefit. Include coding and benefit assignment in the prior authorization and claims documentation.

Charge and code implantable device components under the medical-surgical benefit (e.g., CPT 69930; HCPCS L8614).
Charge and code external components under the DME benefit (e.g., HCPCS L8619, L8627, L8628, V5273).
Clearly document which components are external vs implantable in the medical record and claim submission.
Refer to Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for New Mexico Only) for DME coverage rules.

Step Therapy

Step Therapy Not Specified

This policy does not specify a step-therapy sequence for cochlear implantation. Providers should not expect or be required to follow a prior step-therapy pathway when requesting authorization; follow InterQual clinical criteria instead.

No step-therapy requirements specified in this policy.
Use InterQual criteria and payer-specific prior authorization processes for coverage determination.

Background

Sensorineural hearing loss (SNHL) results from damage to the inner ear (cochlea) or to the auditory nerve pathways and is typically permanent. When SNHL is sufficiently severe to limit speech perception, a cochlear implant may be indicated to bypass damaged hair cells and directly stimulate the auditory nerve.

Cochlear implants can be either non-hybrid (full electrode arrays intended to provide the primary auditory input) or hybrid (combined electric and acoustic stimulation). This policy recognizes cochlear implantation as proven and medically necessary in defined populations: pediatric non-hybrid implantation when the child meets minimum age and clinical criteria, and hybrid or non-hybrid implantation in adults when InterQual criteria are met.

OpenPayer

Cochlear Implants (for New Mexico Only)

Coverage Criteria

Coding and Age Thresholds

Provider Actions and Billing Guidance

Background

Definitions