CurrentUnitedHealthcarePolicy CS019KS.02

Cochlear Implants (for Kansas Only)

UnitedHealthcare Community Plan medical policy for cochlear implants applicable only to members in the state of Kansas, describing coverage stance for non-hybrid and hybrid cochlear implantation by age group and referencing InterQual clinical criteria for medical necessity and Kansas benefit considerations for external components.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for Kansas Only)

Policy CodePolicy CS019KS.02

Change TypeSupporting information / references updated

Effective DateSep 1, 2025

Next Review Date

Key ActionDocument that InterQual CP: Procedures, Cochlear Implantation (adult) or InterQual CP: Procedures, Cochlear Implantation (Pediatric) criteria are met; include clinical details required by InterQual in prior authorization or medical record.

POLICY UPDATE CHANGES

Supporting Information: Updated References section to reflect the most current information; archived previous policy version CS019KS.01.

4Coverage categories described (adult non-hybrid, pediatric bilateral non-hybrid, pediatric single-sided non-hybrid, adult hybrid)

3Minimum age thresholds specified

9Procedure/HCPCS/other codes listed

Coverage Summary

This policy applies only to members in the state of Kansas and uses InterQual® CP: Procedures, Cochlear Implantation (adult and pediatric) as the primary medical necessity standard. Coverage stance is mixed: non-hybrid cochlear implantation is covered for specified adult and pediatric populations and hybrid cochlear implantation is covered for specified adult populations when InterQual criteria are met.

Medical Necessity Criteria (by scenario)

Non-hybrid cochlear implantation - Adults (≥18 years)

Covered when ALL of the following are met:

ALL of the following

Patient is an adult age 18 years or older
Patient has bilateral sensorineural hearing loss and/or single-sided or asymmetric sensorineural hearing loss
Medical necessity clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation are met
Refer to InterQual criteria (link provided in policy)

Non-hybrid cochlear implantation - Pediatrics (bilateral SNHL)

Covered when ALL of the following are met:

ALL of the following

Patient is a child age 6 months or older
Patient has bilateral sensorineural hearing loss
Medical necessity clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation (Pediatric) are met
Refer to InterQual Pediatric criteria (link provided in policy)

Non-hybrid cochlear implantation - Pediatrics (single-sided or asymmetric SNHL)

Covered when ALL of the following are met:

ALL of the following

Patient is a child age 9 months or older
Patient has single-sided or asymmetric sensorineural hearing loss
Medical necessity clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation (Pediatric) are met
Refer to InterQual Pediatric criteria (link provided in policy)

Hybrid cochlear implantation - Adults (≥18 years)

Covered when ALL of the following are met:

ALL of the following

Patient is an adult age 18 years or older
Patient has sensorineural hearing loss
Medical necessity clinical coverage criteria per InterQual CP: Procedures, Cochlear Implantation are met
Refer to InterQual criteria (link provided in policy)

Hybrid cochlear implantation - Pediatrics

Not addressed as covered in this policy for pediatric ages

Policy does not state hybrid cochlear implantation coverage for pediatric patients; InterQual criteria should be consulted if applicable

Not Covered / Experimental Criteria

Non-hybrid cochlear implantation - Not covered (pediatrics below FDA-approved ages)

Not covered / considered experimental or investigational when ANY of the following apply:

ANY of the following

Child with bilateral sensorineural hearing loss younger than 6 months
Considered experimental/investigational due to lack of FDA approval
Child with single-sided or asymmetric sensorineural hearing loss younger than 9 months
Considered experimental/investigational due to lack of FDA approval

Coding

Procedure codesCPTCovered

69930

Cochlear device implantation, with or without mastoidectomy.

Implantable device HCPCS codes (medical-surgical benefit)HCPCSCovered

L8614

Cochlear device, includes all internal and external components.

External component HCPCS codes (DME benefit / replacement)HCPCSCovered

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.

Provider Actions & Billing Rules

Documentation Required

Use InterQual criteria for medical necessity

Document that InterQual CP: Procedures, Cochlear Implantation (adult) or InterQual CP: Procedures, Cochlear Implantation (Pediatric) criteria are met. Include the clinical details required by the applicable InterQual criteria in the prior authorization or medical record to support medical necessity determination.

Billing Rule

Benefit assignment for implantable vs external components

Report implantable cochlear components under the medical‑surgical benefit and external cochlear components (speech processor, microphone, transmitter coil) under the DME benefit per federal/state/contract requirements.

L8614
L8615
L8616
L8617
L8618
L8619
L8627
L8628
V5273

Documentation Required

Reference Kansas DME Fee-for-Service Provider Manual for replacements

For cochlear implants and cochlear external speech processor replacements, follow the Kansas Medical Assistance Program Professional Audiology Fee‑for‑Service Provider Manual instructions and coverage rules.

Background & Definitions

Background: This UnitedHealthcare Community Plan medical policy applies only to Kansas. UnitedHealthcare uses InterQual® clinical criteria as the primary medical/surgical standard for cochlear implantation medical necessity determinations. When InterQual criteria are not applicable, UnitedHealthcare may use other approved medical policies; federal, state, or contractual requirements govern when conflicts exist.

Benefit assignment: the policy states that implantable cochlear components are considered under the medical-surgical benefit, and external cochlear components (speech processor, microphone, transmitter coil) are considered under the DME benefit. Providers should check federal, state, or contractual requirements (including the Kansas DME Fee-for-Service Provider Manual) for specific coverage and replacement rules.

Documentation and provider actions: follow InterQual CP: Procedures, Cochlear Implantation (adult) or InterQual CP: Procedures, Cochlear Implantation (Pediatric) to document medical necessity in prior authorization or the medical record; for cochlear implant external speech processor replacement, refer to the Kansas Medical Assistance Program Professional Audiology Fee-for-Service Provider Manual.

Evidence (informational): the policy references FDA Premarket Approval/Notification resources for cochlear implants — non-hybrid devices (product code MCM) and hybrid devices (product code PGQ) — for informational purposes only; FDA approval alone is not a basis for coverage.

Policy history: the policy was updated effective 09/01/2025 with references updated and the prior version CS019KS.01 archived.

Sensorineural 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. Most of the time, SNHL cannot be medically or surgically corrected. This is the most common type of permanent hearing loss.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (for Kansas Only)

Policy CodePolicy CS019KS.02

Change TypeSupporting information / references updated

Effective DateSep 1, 2025

Next Review Date

On This Page

OpenPayer

Cochlear Implants (for Kansas Only)

Coverage Summary

Medical Necessity Criteria (by scenario)

Not Covered / Experimental Criteria

Coding

Provider Actions & Billing Rules

Background & Definitions

Revision History