Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cochlear implants require pre-authorization.

2)    A cochlear implant is a single or multi-channel electronic device (coil) which consists of electrode(s), a connector, and a sealed receiver-stimulator module encased in silicone rubber that is implanted in patients with severe sensorineural deafness.

3)    The external components of the implant include a microphone, an external sound processor and an external transmitter; surgically implanted internal components include an internal receiver within the temporal bone and an electrode array extending from the receiver into the cochlea through a surgically created opening in the round window of the middle ear.

4)    Cochlear Implants are subject to the terms and conditions of the members plan coverage document.

1)    Adults 18 years of age and older:
Having bilateral, post-linguistic, sensorineural, moderate-to-profound hearing impairment who meet both of the following criteria: HAYES B

i)     Member has bilateral severe to profound sensorineural hearing loss  (H90.3) determined by a pure tone average of 70 dB or greater at 500 Hz, 1000 Hz, and 2000 Hz; and

ii)    Member has limited benefit from appropriately fitted binaural hearing aids. Limited benefit from amplification is defined by test scores of 40 % correct or less in best-aided listening condition on open-set sentence cognition (e.g., Central Institute for the Deaf (CID) sentences, Hearing in Noise Test sentences (HINT)).

2)    Children between 12 months of age and 18 years: HAYES A
Uniaural (monaural) or binaural (bilateral) cochlear implantation is considered  medically necessary for bilateral sensorineural hearing impairment when  all of the following criteria are met :

a)    Child has profound, bilateral sensorineural hearing loss determined by a pure tone average of 90 dB or greater at 500, 1000 and 2000 Hz and

b)    Child has had limited benefit from appropriately fitted binaural hearing aids.
For children 4 years of age or younger, limited benefit is defined as failure to reach developmentally appropriate auditory milestones measured using the Infant-Toddler Meaningful Auditory Integration Scale, the Meaningful Auditory Integration Scale, or the Early Speech Perception test, or less than 20% correct on open-set word recognition test (Multisyllabic Lexical Neighborhood Test) in conjunction with appropriate amplification and participation in intensive aural habilitation over a 3 to 6 month period.
For children older than 4 years of age, limited benefit is defined as less than 12% correct on the Phonetically Balanced-Kindergarten Test, or less than 30% correct on the Hearing in Noise Test for children, the open-set Multi-syllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT), depending on the child`s cognitive ability and linguistic skills; and

c)    A 3- to 6-month hearing aid trial has been undertaken by a child without previous experience with hearing aids. Note: When there is radiological evidence of cochlear ossification, this requirement will be waived.

3)    General criteria for both adults and children:

a)    The member must have no medical contraindications to cochlear implantation (e.g., cochlear aplasia, active middle ear infection); and

b)    The member must have had an assessment by an audiologist and from an otolaryngologist experienced in this procedure indicating the likelihood of success with this device; and

c)    Candidates must be enrolled in an educational program that supports listening and speaking with aided hearing; and

d)    Arrangements for appropriate follow-up care including the long-term speech therapy required to take full advantage of this device, must be assured.

e)    Member is current on age-appropriate pneumococcal vaccination (at least two weeks prior to surgery) in accordance with the Center for Disease Control (CDC) Advisory Committee on Immunization Practices.

Codes Used In This BI:

69930             Implant cochlear device

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, replacement

L8619             Cochlear implant, external speech processor and controller, integrated

                        system, replacement

L8621             Zinc air battery for use with cochlear implant device, replacement, each

L8622             Alkaline battery for use with cochlear implant device, any size,

                        Replacement, each

L8623             Lithium ion battery for use with cochlear implant device speech processor,

                        other than ear level, replacement, each

L8624             Lithium ion battery for use with cochlear implant device speech processor,

                        ear level, replacement, each

L8625             External recharging system for cochlear implant, replacement only

                      (1/1/18)

L8694           Cochlear implant, transducer/actuator, replacement only (1/1/18)

1)    Centers for Medicare and Medicaid Services (CMS). Decision memo for cochlear implantation (CAG-00107N). National Coverage Analyses. Baltimore, MD: CMS; April 4, 2005. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=134&.

2)    National Institute for Clinical Excellence (NICE). Auditory brain stem implants. Interventional Procedure Guidance 108. London, UK: NICE; January 2005.

3)    American Speech-Language-Hearing Association (ASHA). Working Group on Cochlear Implants. Cochlear Implants. ASHA Technical Report. Rockville, MD: ASHA; 2004:1-35. Available at: http://www.asha.org/NR/rdonlyres/215CC9B8-6831-494F-83ED-E02A6832A8A9/0/24402%A01.pdf

4)    Kuhn-Inacker H, Shehata-Dieler W, Muller J, Helms J. Bilateral cochlear implants: A way to optimize auditory perception abilities in deaf children? Int J Pediatric Otorhinolaryngology. 2004;68:1257-1266.

5)    Litovsky RY, Parkinson A, Arcaroli J, Peters R. Bilateral cochlear implants in adults and children. Arch Otolaryngology Head Neck Surg. 2004; 130:648-655.

6)    Ricketts TA, Grantham DW, Ashmead DH, et al. Speech recognition for unilateral and bilateral cochlear implant modes in the presence of uncorrelated noise sources. Ear Hear. 2006;27(6):763-773.

7)    Ching TY, van Wanrooy E, Dillon H. Binaural-bimodal fitting or bilateral implantation for managing severe to profound deafness: A review. Trends Amplif. 2007;11(3):161-192.

8)    National Institute for Health and Clinical Excellence (NICE). Cochlear implants for children and adults with severe to profound deafness. Appraisal Consultation Document. London, UK: NICE; December 2007.