CurrentUnitedHealthcarePolicy CS019.S

Cochlear Implants (Non-hybrid and Hybrid)

Defines UnitedHealthcare's medical policy on cochlear implants, including applicability by age and laterality, references InterQual clinical criteria for medical necessity, states where policy does not apply, benefit considerations for DME vs medical-surgical, applicable CPT/HCPCS codes, and FDA informational links.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (Non-hybrid and Hybrid)

Policy CodePolicy CS019.S

Change TypeTemplate updates; state applicability additions

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must reference and meet InterQual CP: Procedures, Cochlear Implantation (adult) or InterQual CP: Procedures, Cochlear Implantation (Pediatric) clinical criteria to establish medical necessity for cochlear implantation.

POLICY UPDATE CHANGES

04/01/2026: Template Update; removed content/language pertaining to the state of Louisiana.

10/01/2025: Added language indicating the Medical Policy does not apply to the state of Nebraska; refer to state-specific policy.

09/01/2025: Added Medical Records Documentation Used for Reviews language clarifying that coverage is determined by federal/state/contractual requirements and that records may be required.

3Covered Age/Indication Categories (adult non-hybrid, adult hybrid, pediatric non-hybrid ≥6/9 months)

2Not Applicable States Listed

Coverage Summary

This policy addresses coverage for Cochlear Implants (Non-hybrid and Hybrid). UnitedHealthcare defines applicability by age and laterality and references InterQual clinical criteria to determine medical necessity. The policy is mixed in stance and applies effective 2025-09-01 with last review on 2026-04-01.

Policy NumberCS019.S

SubjectCochlear Implants (Non-hybrid and Hybrid)

Effective DateSeptember 1, 2025

Last ReviewApril 1, 2026

StatusCURRENT

Scope SummaryDefines UnitedHealthcare's medical policy on cochlear implants, including applicability by age and laterality, references InterQual clinical criteria for medical necessity, states where policy does not apply, benefit considerations for DME vs medical-surgical, applicable CPT/HCPCS codes, and FDA informational links.

Covered Age/Indication Categories (stat) 3

Not Applicable States Listed (stat)2

Medical-Necessity Criteria

Coverage Criteria Overview

ALL of the following

Adult non-hybrid coverage
- 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 ages 18 and older.
Pediatric non-hybrid coverage
- Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral Sensorineural Hearing Loss in children ages 6 months or older.
- Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for single-sided or asymmetric Sensorineural Hearing Loss in children ages 9 months or older.
- Non-hybrid cochlear 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.
  These younger-age indications are considered not proven/experimental; see FDA information in the policy.
Hybrid cochlear implant coverage
- Hybrid cochlear implantation is proven and medically necessary under certain circumstances for Sensorineural Hearing Loss in adults ages 18 and older.

Documentation Required

Reference InterQual criteria for medical necessity determination

InterQual CP: Procedures, Cochlear Implantation (adult and pediatric) must be used to establish clinical medical necessity for cochlear implantation.

69930

Not Proven / Experimental Indications

Pediatric experimental/ investigational age thresholds

Pediatric younger-age experimental/ investigational statement: 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 Food and Drug Administration (FDA) approval.

Not proven/experimental because these indications lack FDA approval; see FDA section for informational links.

Coding

Procedure CPTCPT

69930

Cochlear device implantation, with or without mastoidectomy.

HCPCS Implantable and External Device CodesHCPCS

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.

Billing Rule

Benefit consideration by benefit type

External cochlear implant components (speech processor, microphone, transmitter coil, etc.) are considered under the DME benefit while implantable components are considered under the medical‑surgical benefit; check federal, state, or contractual plan requirements for applicability.

L8614
L8615
L8616
L8617
L8618
L8619
L8627
L8628
V5273
69930

Provider Actions

Documentation Required

Medical records may be requested

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage, and documentation does not guarantee coverage of the service requested.

Documentation Required

Reference InterQual criteria for medical necessity determination

InterQual CP: Procedures, Cochlear Implantation (adult) and InterQual CP: Procedures, Cochlear Implantation (Pediatric) should be referenced to determine whether clinical criteria for cochlear implantation are met.

69930

Background

Non-hybrid cochlear implantation is described as proven and medically necessary under certain circumstances for bilateral sensorineural hearing loss and for single-sided or asymmetric sensorineural hearing loss in adults ages 18 and older; InterQual CP: Procedures, Cochlear Implantation is referenced for specific medical necessity clinical coverage criteria. Non-hybrid cochlear implantation is also described as proven and medically necessary under certain circumstances for bilateral SNHL in children ages 6 months or older and for single-sided or asymmetric SNHL in children ages 9 months or older. The policy notes that non-hybrid cochlear 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 FDA approval.

Hybrid cochlear implantation is described as proven and medically necessary under certain circumstances for sensorineural hearing loss in adults ages 18 and older, with InterQual criteria referenced for clinical determination.

The policy distinguishes benefit responsibility: external cochlear implant components (speech processor, microphone, transmitter coil) are considered under the DME benefit, while implantable components are considered under the medical-surgical benefit; plan-specific federal/state/contractual requirements should be checked. Medical records documentation may be required to assess whether a member meets clinical criteria but does not guarantee coverage.

This Medical Policy does not apply to certain states; where noted, refer to the state-specific policy or guideline (examples listed include Nebraska and other states).

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 SNHL cannot be medically or surgically corrected and is the most common type of permanent hearing loss.

Revision History

04/01/2026revisedLatest

04/01/2026: Template Update; removed content/language pertaining to the state of Louisiana.

10/01/2025added

10/01/2025: Added language indicating the Medical Policy does not apply to the state of Nebraska; refer to state-specific policy.

09/01/2025revised

09/01/2025: Added Medical Records Documentation Used for Reviews language clarifying that coverage is determined by federal/state/contractual requirements and that records may be required.

Policy Summary

PayerUnitedHealthcare

PolicyCochlear Implants (Non-hybrid and Hybrid)

Policy CodePolicy CS019.S

Change TypeTemplate updates; state applicability additions

Effective DateSep 1, 2025

Next Review Date

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