CurrentUnitedHealthcarePolicy CS019TN.R

Cochlear Implants (for Tennessee Only)

Defines UnitedHealthcare medical policy for cochlear implants applicable to Tennessee Medicaid and CoverKids members, focusing on age-based indications and referencing InterQual criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for Tennessee Only)

Policy CodePolicy CS019TN.R

Change TypeMedical records documentation language added

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure the patient's medical record fully documents medical necessity, including history, exam, and diagnostic test results, and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews section added specifying documentation requirements to support medical necessity.

Supporting Information updated and References section refreshed; previous policy version archived.

under 21Policy applies to individuals under this age

18+Adult coverage age

6 moPediatric bilateral minimum age

9 moPediatric single-sided minimum age

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Medically Necessary Indications

Covered when criteria (per InterQual) and age-based indications are met:

Adult non-hybrid: 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

Refer to InterQual CP: Procedures, Cochlear Implantation for clinical criteria

Pediatric bilateral non-hybrid: Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral Sensorineural Hearing Loss in children.age >= 6 months

Refer to InterQual CP: Procedures, Cochlear Implantation (Pediatric)

Pediatric single-sided/asymmetric non-hybrid: Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for single-sided or asymmetric Sensorineural Hearing Loss in children.age >= 9 months

Refer to InterQual CP: Procedures, Cochlear Implantation (Pediatric)

Adult hybrid: Hybrid cochlear implantation is proven and medically necessary under certain circumstances for Sensorineural Hearing Loss in adults.age >= 18

Refer to InterQual CP: Procedures, Cochlear Implantation

Experimental/Investigational

Not covered / investigational:

Pediatric younger than minimum ages: 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 (bilateral) OR age < 9 months (single-sided/asymmetric)

FDA approval status cited

Non-hybrid cochlear implantation in pediatric patients is governed by age-based thresholds tied to FDA approval. Non-hybrid cochlear implantation is considered proven and medically necessary for bilateral sensorineural hearing loss in children age 6 months or older, and for single-sided or asymmetric sensorineural hearing loss in children age 9 months or older. Procedures performed in children younger than these minimum ages—under 6 months for bilateral SNHL or under 9 months for single-sided/asymmetric SNHL—are considered experimental or investigational due to lack of FDA approval and are excluded from coverage under this policy.

Clinical coverage determinations reference InterQual clinical criteria and FDA age-based approvals. Procedures that do not meet the InterQual clinical coverage criteria or that fall below the FDA age thresholds described in this policy may not be considered medically necessary and are not eligible for coverage.

Coding and Age Thresholds

Covered CPT CodesCPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS Codes (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

Age thresholds for coverage — cochlear implants

Adult (non-hybrid and hybrid)Coverage for cochlear implantation applies to adults age 18 years and older.

Pediatric — bilateral non-hybridCoverage for non-hybrid cochlear implantation for bilateral SNHL applies to children age 6 months and older.

Pediatric — single-sided/asymmetric non-hybridCoverage for non-hybrid cochlear implantation for single-sided or asymmetric SNHL applies to children age 9 months and older.

Not covered — pediatric below thresholdsNon-hybrid cochlear implantation is considered experimental/investigational for bilateral SNHL in children younger than 6 months and for single-sided/asymmetric SNHL in children younger than 9 months due to lack of FDA approval.

Provider Actions and Documentation Requirements

Billing Rule

Coding and benefit assignment

Check the member’s benefit plan to determine whether external components (speech processor, microphone, transmitter coil) are the responsibility of the durable medical equipment (DME) benefit and implantable components are the responsibility of the medical-surgical benefit. Federal, state, or contractual requirements may affect benefit assignment — verify coverage and any applicable policy references prior to billing.

External cochlear implant components (speech processor, microphone, transmitter coil) typically billed to DME benefit
Implantable cochlear device components typically billed to medical-surgical benefit
Refer to Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (Tennessee) and member contract

Documentation Required

Patient medical record must fully support medical necessity

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

History: relevant hearing history, prior treatments, and prior amplification trials
Exam: findings from otologic and audiologic examinations
Testing: audiograms, speech recognition scores, imaging (if required), and other pertinent diagnostic results

Denial Risk

Lack of adequate medical record documentation may result in denial

Lack of adequate medical record documentation may result in claim denial or delay. Ensure records submitted for review clearly demonstrate that the clinical criteria for the requested service are met and include all supporting materials referenced in the policy. Failure to provide requested records upon request may adversely affect coverage determination.

Insufficient or missing history, exam findings, or diagnostic test results increases denial risk
Provide complete, legible records when responding to requests for clinical review

Note

Provider actions

Provide requested documentation promptly and ensure medical records are comprehensive and retrievable for audits and reviews. Providers should follow payer-specific submission instructions and include copies of all pertinent reports to support medical necessity.

Maintain legible, timely documentation in the patient’s chart
Respond to record requests per UnitedHealthcare guidelines

OpenPayer

Cochlear Implants (for Tennessee Only)

Coverage Criteria

Coding and Age Thresholds

Provider Actions and Documentation Requirements

Background

Definitions