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Cochlear Implantation
11.01.02r

Policy

MEDICALLY NECESSARY

A unilateral or bilateral implantation of a US Food and Drug Administration (FDA)-approved single- or multichannel cochlear implant is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has a documented diagnosis of bilateral pre- or postlinguistic moderate-to-profound sensorineural hearing impairment with limited benefit from hearing (or vibrotactile) aids.
    • ​Moderate-to-profound sensorineural hearing impairment is defined as: 
      • Moderate hearing loss: bilateral hearing threshold of 40-60 dB.
      • Severe hearing loss: bilateral hearing threshold of 70-90 dB.​
      • Profound hearing loss: bilateral hearing threshold of 90 dB and above.
    • ​Limited benefit from hearing aids/amplification or vibrotactile aids is defined as: 
      • In adults (18 years of age and older), test scores of less than or equal to 50% correct on tape-recorded tests of open-set sentence cognition in the best-aided listening condition.
      • ​In children (9 months to 17 years of age), ​a failure to develop basic auditory skills,​ ​and in older children, ​​30% or less correct on open-set tests in the best-aided listening condition.
  • The individual has the cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation, appropriate for their age (e.g., >18 months).  
  • The cochlear lumen is accessible, structurally suited to implantation, free of middle ear infection, and free of lesions in the auditory nerve and acoustic areas of the central nervous system.
  • A cochlear implant must be used in accordance with the labeling approved by the FDA.
Cochlear implantation with a hybrid cochlear implant/hearing aid device that includes the hearing aid integrated into the external sound processor of the cochlear implant (e.g., the Nucleus® Hybrid™ L24 Cochlear Implant System) is considered medically necessary and, therefore, covered for individuals ages 18 years and older when all of the following criteria are met:​
  • Bilateral severe-to-profound high-frequency sensorineural hearing loss with residual low-frequency hearing sensitivity
  • Received limited benefit from appropriately fit bilateral hearing aids
  • Have all of the following hearing thresholds:
    • Low-frequency hearing thresholds no poorer than 60 dB hearing level up to and including 500 Hz (averaged over 125, 250, and 500 Hz) in the ear selected for implantation
    • Severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz ≥75 dB hearing level) in the ear to be implanted
    • Moderately severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz ≥60 dB hearing level) in the contralateral ear
    • Aided consonant-nucleus-consonant word recognition score from 10% to 60% in the ear to be implanted in the preoperative aided condition and in the contralateral ear will be equal to or better than that of the ear to be implanted but not more than 80% correct.
Accessories for covered devices required for the proper functioning of a cochlear implant (e.g., specialized batteries), including replacement items, are considered medically necessary and, therefore, covered.

Replacement of internal and/or external components is considered medically necessary and, therefore, covered only in a small subset of individuals who have inadequate response to existing component(s) to the point of interfering with the individual’s activities of daily living, or the component(s) is/are no longer functional and cannot be repaired.

When a member has a benefit for hearing aids and assistive listening devices, an assistive listening device for use with a cochlear implant approved by the FDA is covered for individuals who have a cochlear implant.

AURAL REHABILITATION 

Aural rehabilitation and training (also known as auditory rehabilitation) associated with a cochlear implantation is covered and eligible for reimbursement if the individual meets the medical necessity criteria listed above for the implantation of the device.
EXPERIMENTAL/INVESTIGATIONAL

Cochlear implantation for the treatment of unilateral hearing loss with or without tinnitus is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature. 

NOT MEDICALLY NECESSARY

All indications for cochlear implantation other than those listed in this policy are considered not medically necessary and, therefore, not covered.​

Replacement of internal and/or external components solely for the purpose of upgrading to a system with advanced technology, upgrading to a next-generation device, or replacing for aesthetic improvement is not eligible for payment under the medical benefits of the Company’s products because the service is considered not medically necessary and, therefore, not covered.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

An order for each item billed must be signed and dated by the professional provider who is treating the member and kept on file by the supplier. Medical record documentation must include a shipment confirmation or member's receipt of supplies and equipment. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Claims submitted for cochlear implantation must be reported with the appropriate medical codes representing the most specific condition and laterality.​​

Aural rehabilitation services reported using Current Procedural Terminology (CPT) codes 92626, 92627, 92630, and 92633 are not considered speech therapy and, therefore, are not applied to the member's speech therapy benefit. 

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, cochlear implantation (unilateral and bilateral) is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Subject to the terms and conditions of the applicable benefit contract, upgrades to an existing external cochlear implant system for aesthetic improvement or replacement of internal and/or external components solely for the purpose of upgrading to a system with advanced technology or to a next-generation device is not eligible for payment under the medical benefits of the Company’s products because the service is considered not medically necessary and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

DURATION OF AURAL REHABILITATION

Aural rehabilitation and training (post-cochlear implant) is necessary to attain benefits from a cochlear implant. It generally consists of six to 10 sessions that last approximately 2 hours each.


MANDATES
 

 The laws of the state where the group benefit contract is issued determine the mandated coverage.


US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous cochlear implant devices approved by the FDA.

Description

There are three basic types of hearing loss: conductive, sensorineural, and mixed. Conductive hearing loss occurs when there is damage to the middle ear. Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or to the nerve pathways from the inner ear to the brain. Mixed hearing loss is when both the middle ear and inner are damaged.  ​

A cochlear implant allows direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or improperly functioning in the cochlea of an individual who has moderate, severe, or profound sensorineural hearing impairment. A cochlear implant device is indicated for individuals with moderate, severe, or profound bilateral sensorineural hearing impairment who only received limited benefit from amplification with hearing aids.

There is a distinction between cochlear implants and cochlear hearing aids. Cochlear implants have external components, as well as certain internal components that are surgically implanted in the ear. Cochlear implants are not classified as hearing aids because they produce an electrical signal that directly stimulates the auditory nerve, unlike a hearing aid that just makes sound louder or clearer.

COMPONENTS

The implant consists of external and internal components. The external components include a microphone, a sound processor, and a transmitter. The internal components are implanted surgically and include a receiver placed in the temporal bone and an electrode array that extends from the receiver into the cochlea through an opening in the round window of the middle ear.

Sounds picked up by the microphone are carried to the external sound processor, which then transforms sounds into coded signals that are transmitted transcutaneously to the implanted receiver. The receiver converts the incoming signals to electrical impulses that are then conveyed to the electrode array, ultimately resulting in the stimulation of the auditory nerve. The device provides for both the awareness and the identification of sounds in order to facilitate communication in individuals who have been diagnosed as hearing impaired.

BILATERAL COCHLEAR IMPLANTATION

The auditory benefits of bilateral cochlear implants are to improve the understanding of speech in noise and the localization of sounds (or spatial hearing). Improvements in speech intelligibility may occur with bilateral cochlear implants through binaural summation (i.e., signal processing of sound input from two sides). Binaural summation is thought to provide a better representation of sound and allows individuals to separate noise from speech. Speech intelligibility and localization of sound may also be improved with head shadow and squelch effects (i.e., when the ear that is closer to the noise receives sound at a different frequency and intensity). Head shadow and squelch effects allow individuals to sort noise and identify the direction of sound.

Bilateral cochlear implantation may be performed independently with separate implants and speech processors in each ear. Bilateral cochlear implantation may also be performed with a single processor. However, no single processor for bilateral cochlear implantation has been approved by the US Food and Drug Administration (FDA) for use in the United States. In addition, single processors do not provide binaural benefit and may impair localization and increase the signal-to-noise ratio received by the cochlear implant.

​The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) published an updated position statement on Pediatric Cochlear Implants endorsing the use of cochlear implants when the individual has bilateral severe-to-profound sensorineural hearing loss before 12 months​.
UNILATERAL HEARING LOSS 

 A number of small observational studies from outside the United States have reported results on cochlear implantation in adults with unilateral deafness, which would be an off-label indication. For example, Arndt et al. published a German pilot study in 2010 of 11 adults with unilateral hearing loss of various causes, looking at the use of unilateral electrical stimulation with normal hearing on the contralateral side after a period of 6 months compared with conventional contralateral routing of signal or bone-anchored hearing aids. Ten of the 11 study participants also suffered from tinnitus. The authors reported that cochlear implantation improved hearing abilities in these study participants and was superior to conventional contralateral routing of signal or bone-anchored hearing aids. The use of the cochlear implant did not interfere with speech understanding in the normal-hearing ear.

In a systematic review, Cabral Junior et al. (2016) evaluated the available recent studies on the outcomes of cochlear implantation in patients with single-sided deafness (SSD) in regards to speech discrimination, sound localization, and tinnitus suppression. The authors concluded although some studies had shown encouraging results on cochlear implantation and SSD, all failed to provide a high level of evidence. Larger studies are necessary to define the tangible benefits of cochlear implantation in individuals with SSD.​​

In a systematic review, Van Zon et al. (2015) reviewed the available literature on the clinical outcome of cochlear implantation for patients with SSD or asymmetrical hearing loss (AHL). The authors found no high level of evidence studies concerning cochlear implantation in patients with SSD or AHL. The current literature suggested important benefits of cochlear implantation regarding sound localization, quality of life, and tinnitus. Varying results were reported for speech perception in noise, possibly caused by the large clinical heterogeneity between studies. Larger and high-quality studies are warranted.

The application of cochlear implants for tinnitus relief in people with unilateral deafness has also been described in earlier studies. For example, van de Heyning et al. published a study in 2008 of 21 people with unilateral hearing loss accompanied by severe tinnitus for at least 2 years who underwent cochlear implantation at a University Center in Belgium. Three of the 21 study participants showed complete tinnitus relief, whereas the majority demonstrated a significant reduction in tinnitus loudness based on a visual analogue scale (2 years after implantation). The evidence-base to date on unilateral hearing loss is based on a few observational studies with a small number of study participants. Future controlled studies with appropriate participant selection comparing cochlear implants to alternative treatment options are needed to yield stronger evidence.

HYBRID COCHLEAR IMPLANTATION

In March 2014, the FDA approved the Nucleus® Hybrid™ L24 Cochlear Implant System (Cochlear Corporation, Centennial, CO), an electroacoustic stimulation system, through the premarket approval process. This system is a hybrid cochlear implant and hearing aid, with the hearing aid integrated into the external sound processor of the cochlear implant. It is indicated for unilateral use in individuals aged 18 years and older who have severe to profound mid- and high-frequency sensorineural hearing loss and normal to moderate low-frequency hearing loss, and who obtain limited benefit from an appropriately fit bilateral hearing aid.
AURAL REHABILITATION

Aural rehabilitation (also known as auditory rehabilitation) is a postcochlear implant program that focuses on improving the individual's ability to interpret auditory information that is received through the implant. The program emphasizes the recognition of specific speech sounds, word discrimination and identification, and conversational skills.

References

American Academy of Otolaryngology–Head and Neck Surgery Foundation. Position Statement on Cochlear Implants. 11/10/2020. Available at: Position Statement: Cochlear Implants - American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) (entnet.org). Accessed March 05, 2024.

American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS). Position Statement: Pediatric Cochlear Implant Candidacy. 04/05/2021. Available at:  https://www.entnet.org/?s=https://www.entnet.org/resource/position-statement-pediatric-cochlear-implantation-candidacy/. Accessed on March 05, 2024.

American Speech-Language-Hearing Association (ASHA). Cochlear implants. [ASHA Web site]. Available at: http://www.asha.org/public/hearing/Cochlear-Implant/. Accessed March 05, 2024.

American Speech-Language-Hearing Association (ASHA). Type, degree, and configuration of hearing loss. [ASHA Web site]. Available at: https://www.asha.org/siteassets/ais/ais-type-degree-and-configuration-of-hearing-loss.pdf.   Accessed March 05, 2024.

Arndt S, Aschendorff A, Laszig R, et al. Comparison of pseudobinaural hearing to real binaural hearing rehabilitation after cochlear implantation in patients with unilateral deafness and tinnitus. Otol Neurotol. 2011;32(1):39-47.

Arndt S, Prosse S, Laszig R, et al. Cochlear implantation in children with single-sided deafness: does aetiology and duration of deafness matter? Audiol Neurootol. 2015;20 Suppl 1:21-30.

Arts RA, George EL, Stokroos RJ, et al. Review: cochlear implants as a treatment of tinnitus in single-sided deafness. Curr Opin Otolaryngol Head Neck Surg. 2012;20(5):398-403.

Au DK, Hui Y, Wei WI. Superiority of bilateral cochlear implantation over unilateral cochlear implantation in tone discrimination in Chinese patients. Am J Otolaryngol. 2003;24(1):19-23.

Berrettini S, Baggiani A, Bruschini L, et al. Systematic review of the literature on the clinical effectiveness of the cochlear implant procedure in adult patients. Acta Otorhinolaryngol Ital. 2011;31(5):299-310.

Bittencourt AG, Ikari LS, Della Torre AA, et al. Post-lingual deafness: benefits of cochlear implants vs. conventional hearing aids. Braz J Otorhinolaryngol. 2012;78(2):124-127.

Black J, Hickson L, Black B, et al. Prognostic indicators in paediatric cochlear implant surgery: a systematic literature review. Cochlear Implants Int. 2011;12(2):67-93.

Blakely BW. Hearing: when surgery is appropriate for age-related hearing loss. In: Geriatric Care Otolaryngology. American Academy of Otolaryngology–Head and Neck Surgery Foundation. 2006. Pages 11-14.

Blamey PJ, Maat B, Baskent D, et al. A retrospective multicenter study comparing speech perception outcomes for bilateral implantation and bimodal rehabilitation. Ear Hear. 2015;36(4):408-16.

Blasco MA, Redleaf MI. Cochlear implantation in unilateral sudden deafness improves tinnitus and speech comprehension: meta-analysis and systematic review. Otol Neurotol. 2014;35(8):1426-32.

Bond M, Mealing S, Anderson R, et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess. 2009;13(44):1-330.

Bond M, Elston J, Mealing S, et al. Effectiveness of multi-channel unilateral cochlear implants for profoundly deaf children: a systematic review. Clin Otolaryngol. 2009;34(3):199-211.

Bond M, Elston J, Mealing S, et al. Systematic reviews of the effectiveness and cost-effectiveness of multi-channel unilateral cochlear implants for adults. Clin Otolaryngol. 2010;35(2):87-96.

Broomfield SJ, Murphy J, Emmett S, et al. Results of a prospective surgical audit of bilateral paediatric cochlear implantation in the UK. Cochlear Implants Int. 2013;14 Suppl 4:S19-21.

Buss E, Pillsbury HC, Buchman CA, et al. Multicenter U.S. bilateral MED-EL cochlear implantation study: speech perception over the first year of use. Ear Hear. 2008;29(1):20-32.


Cabral Junior F, Pinna MH, Alves RD, et al. Cochlear implantation and single-sided deafness: a systematic review of the literature. Int Arch Otorhinolaryngeal. 2016;20(1):69-75.

Causon A, Verschuur C, Newman TA. A retrospective analysis of the contribution of reported factors in cochlear implantation on hearing preservation outcomes. Otol Neurotol. 2015;36(7):1137-45.

Centers for Medicare & Medicaid Services (CMS). Cochlear Implantation: Decision Memo (CAG-00107N). [CMS Web site]. 04/04/2005. Available at:
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=134. Accessed March 05, 2024.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 50.3: Cochlear implantation. [CMS Web site]. 04/04/2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=245&ncdver=2&bc=BAABAAAAAAAA&. Accessed March 05, 2024.

Ching TY, Dillon H, Day J, et al. Early language outcomes of children with cochlear implants: interim findings of the NAL study on longitudinal outcomes of children with hearing impairment. Cochlear Implants Int. 2009;10(suppl 1):28-32.

Ching TY, Incerti P, Hill M. Binaural benefits for adults who use hearing aids and cochlear implants in opposite ears. Ear Hear. 2004;25(1):9-21.

Ching TY, Incerti P, Hill M, van Wanrooy E. An overview of binaural advantages for children and adults who use binaural/bimodal hearing devices. Audiol Neurootol. 2006;11(suppl 1):6-11.

Choi JS, Betz J, Li L, et al. Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults. JAMA Otolaryngol Head Neck Surg. 2016;142(7):652-657.

ClinicalTrials.gov. Evaluation of revised indicatons (ERID) for cochlear implant candidacy for the adult CMS population [Clinical Trials.gov Web site]. 07/27/2021 Available at:https://clinicaltrials.gov/ct2/show/NCT02075229. Accessed ​March 05, 2024.​

Colletti L. Long-term follow-up of infants (4-11 months) fitted with cochlear implants. Acta Otolaryngol. 2009;129(4):361-366.

Colletti L, Mandala M, Zoccante L, et al. Infants versus older children fitted with cochlear implants: performance over 10 years. Int J Pediatr Otorhinolaryngol. 2011;75(4):504-509.

Crathorne L, Bond M, Cooper C, et al. A systematic review of the effectiveness and cost-effectiveness of bilateral multichannel cochlear implants in adults with severe-to-profound hearing loss. Clin Otolaryngol. 2012;37(5):342-54.

Escorihuela Garcia V, Pitarch Ribas MI, Llopez Carratala I, et al. Comparative study between unilateral and bilateral cochlear implantation in children of 1 and 2 years of age. Acta Otorrinolaringol Esp. 2015;67(3):148-155.

Eze N, Ofo E, Jiang D, et al. Systematic review of cochlear implantation in children with developmental disability. Otol Neurotol. 2013;34(8):1385-93.

Fernandes NF, Morettin M, Yamaguti EH, et al. Performance of hearing skills in children with auditory neuropathy spectrum disorder using cochlear implant: a systematic review. Braz J Otorhinolaryngol. 2015;81(1):85-96.

Friedmann DR, Green J, Fang Y, et al. Sequential bilateral cochlear implantation in the adolescent population. Laryngoscope. 2015;125(8):1952-1958.

Friedmann DR, Peng R, Fang Y, et al. Effects of loss of residual hearing on speech performance with the CI422 and the Hybrid-L electrode. Cochlear Implants Int. 2015;16(5):277-284.

Firszt JB, Reeder RM, Skinner MW. Restoring hearing symmetry with two cochlear implants or one cochlear implant and a contralateral hearing aid. J Rehabil Res Dev. 2008;45(5):749-767.

Forli F, Arslan E, Bellelli S, et al. Systematic review of the literature on the clinical effectiveness of the cochlear implant procedure in paediatric patients. Acta Otorhinolaryngol Ital. 2011; 31(5):281-298.

Galvin KL, Mok M, Dowell RC. Perceptual benefit and functional outcomes for children using sequential bilateral cochlear implants. Ear Hear. 2007;28(4):470-482.

Gantz BJ, Tyler RS, Rubinstein JT, et al. Binaural cochlear implants placed during the same operation. Otol Neurotol. 2002;23(2):169-180.

Gaylor JM, Raman G, Chung M, et al. Cochlear implantation in adults: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2013;139(3):265-272.

Gifford RH, Dorman MF, Skarzynski H, et al. Cochlear implantation with hearing preservation yields significant benefit for speech recognition in complex listening environments. Ear Hear. 2013;34(4):413-425.

Grantham DW, Ashmead DH, Ricketts TA, et al. Horizontal-plane localization of noise and speech signals by postlingually deafened adults fitted with bilateral cochlear implants. Ear Hear. 2007;28(4):524-541.

Guerzoni L, Murri A, Fabrizi E, et al. Social conversational skills development in early implanted children. Laryngoscope. 2015;67(3):148-155.

Hansen MR, Gantz BJ, Dunn C. Outcomes after cochlear implantation for patients with single-sided deafness, including those with recalcitrant Meniere's disease. Otol Neurotol. 2013;34(9):1681-1687.

Harkonen K, Kivekas I, Rautiainen M, et al. Sequential bilateral cochlear implantation improves working performance, quality of life, and quality of hearing. Acta Otolaryngol. 2015;135(5):440-446.

Holt RF, Kirk KI, Eisenberg LS, et al. Spoken word recognition development in children with residual hearing using cochlear implants and hearing AIDS in opposite ears. Ear Hear. 2005;26(4 suppl):82S-91S.

Humphriss R, Hall A, Maddocks J, et al. Does cochlear implantation improve speech recognition in children with auditory neuropathy spectrum disorder? A systematic review. Int J Audiol. 2013;52(7):442-454.

Illg A, Giourgas A, Kral A, et al. Speech comprehension in children and adolescents after sequential bilateral cochlear implantation with long interimplant interval. Otol Neurotol. 2013;34(4):682-689.

Johr M, Ho A, Wagner CS, Linder T. Ear surgery in infants under one year of age: its risks and implication for cochlear implant surgery. Otol Neurotol. 2008;29(3):310-313.

Kamal SM, Robinson AD, Diaz RC. Cochlear implantation in single-sided deafness for enhancement of sound localization and speech perception. Curr Opin Otolaryngol Head Neck Surg. 2012;20(5):393-397.

Kontorinis G, Lloyd SK, Henderson L, et al. Cochlear implantation in children with auditory neuropathy spectrum disorders. Cochlear Implants Int. 2014;15 Suppl 1:S51-54.

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 Pediatr Otorhinolaryngol. 2004;68(10):1257-1266.

Lammers MJ, van der Heijden GJ, Pourier VE, et al. Bilateral cochlear implantation in children: a systematic review and best evidence synthesis. Laryngoscope.2014;24(7):1694-1699.

Lawson DT, Wilson BS, Zerbi M, et al. Bilateral cochlear implants controlled by a single speech processor. Am J Otol. 1998;19(6):758-761.

Lenarz T, James C, Cuda D, et al. European multi-centre study of the Nucleus Hybrid L24 cochlear implant. Int J Audiol. 2013;52(12):838-848.

Litovsky RY, Johnstone PM, Godar S, et al. Bilateral cochlear implants in children: localization acuity measures with minimum audible angle. Ear Hear. 2006;27(1):43-59.

Litovsky R, Parkinson A, Arcaroli J, Sammeth C. Simultaneous bilateral cochlear implantation in adults: a multicenter clinical study. Ear Hear. 2006;27(6):714-731.

Long CJ, Eddington DK, Colburn HS, Rabinowitz WM. Binaural sensitivity as a function of interaural electrode position with a bilateral cochlear implant user. J Acoust Soc Am. 2003;114(3):1565-1574.

Luntz M, Yehudai N, Shpak T. Hearing progress and fluctuations in bimodal-binaural hearing users (unilateral cochlear implants and contralateral hearing aid). Acta Otolaryngol. 2007;127(10):1045-1050.

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Morera C, Manrique M, Ramos A, et al. Advantages of binaural hearing provided through bimodal stimulation via a cochlear implant and a conventional hearing aid: a 6-month comparative study. Acta Otolaryngol. 2005;125(6):596-606.

Muller J, Schon F, Helms J. Speech understanding in quiet and noise in bilateral users of the MED-EL COMBI 40/40+ cochlear implant system. Ear Hear. 2002;23(3):198-206.

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New Jersey Senate Bill 164 (2024) requires health benefits coverage of hearing aids and cochlear implants for insureds aged 21 or younger. Available at: https://legiscan.com/NJ/text/S164/2024. Accessed March 19, 2024.

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Pakdaman MN, Herrmann BS, Curtin HD, et al. Cochlear implantation in children with anomalous cochleovestibular anatomy: a systematic review. Otolaryngol Head Neck Surg. 2012;146(2):180-90.

Raman G, Lee J, Chung M, et al. Effectiveness of Cochlear Implants in Adults with Sensorineural Hearing Loss. Technology Assessment Report. June 17, 2011. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id80TA.pdf. Accessed March 05, 2024.

Ramos Macias A, Falcon Gonzalez JC, Manrique M, et al. Cochlear implants as a treatment option for unilateral hearing loss, severe tinnitus and hyperacusis. Audiol Neurootol. 2015;20 Suppl 1:60-66.

Ramsden R, Greenham P, O'Driscoll M, et al. Evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system. Otol Neurotol. 2005;26(5):988-998.

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.

Roland JT, Jr., Gantz BJ, Waltzman SB, et al. United States multicenter clinical trial of the cochlear nucleus hybrid implant system. Laryngoscope. 2016;126(1):175-181.

Roush P, Frymark T, Venediktov R, et al. Audiologic management of auditory neuropathy spectrum disorder in children: a systematic review of the literature. Am J Audiol. 2011;20(2):159-170.

Sampaio AL, Araujo MF, Oliveira CA. New criteria of indication and selection of patients to cochlear implant. Int J Otolaryngol. 2011; 2011:573968.

Santa Maria PL, Gluth MB, Yuan Y, et al. Hearing preservation surgery for cochlear implantation: a metaanalysis. Otol Neurotol. 2014;35(10):e256-269.

Sarant J, Harris D, Bennet L, et al. Bilateral versus unilateral cochlear implants in children: a study of spoken language outcomes. Ear Hear. 2014;35(4):396-409.

Scherf F, van Deun L, van Wieringen A, et al. Hearing benefits of second-side cochlear implantation in two groups of children. Int J Pediatr Otorhinolaryngol. 2007;71(12):1855-1863.

Schoen F, Mueller J, Helms J, Nopp P. Sound localization and sensitivity to interaural cues in bilateral users of the Med-El Combi 40/40+ cochlear implant system. Otol Neurotol. 2005;26(3):429-437.

Schon F, Muller J, Helms J. Speech reception thresholds obtained in a symmetrical four-loudspeaker arrangement from bilateral users of MED-EL cochlear implants. Otol Neurotol. 2002;23(5):710-714.

Sharma A, Dorman MF. Central auditory development in children with cochlear implants: clinical implications. Adv Otorhinolaryngol. 2006;64:66-88.

Sharma A, Dorman MF, Kral A. The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hear Res. 2005;203(1-2):134-143.

Smulders YE, Rinia AB, Rovers MM, et al. What is the effect of time between sequential cochlear implantations on hearing in adults and children? A systematic review of the literature. Laryngoscope. 2011;121(9):1942-1949.

Sparreboom M, van Schoonhoven J, van Zanten BG, et al. The effectiveness of bilateral cochlear implants for severe-to-profound deafness in children: a systematic review. Otol Neurotol. 2010; 31(7):1062-1071.

Sterkers F, Merklen F, Piron JP, et al. Outcomes after cochlear reimplantation in children. Int J Pediatr Otorhinolaryngol. Int J Pediatr Otorhinolaryngol. 2015;79(6):840-3.

Tavora-Vieira D, Marino R, Krishnaswamy J, et al. Cochlear implantation for unilateral deafness with and without tinnitus: a case series. Laryngoscope. 2013;123(5):1251-5.

Thai-Van H, Gallego S, Truy E, et al. Electrophysiological findings in two bilateral cochlear implant cases: does the duration of deafness affect electrically evoked auditory brain stem responses? Ann Otol Rhinol Laryngol. 2002;111(11):1008-1014.

Truy E, Ionescu E, Ceruse P, Gallego S. The binaural digisonic cochlear implant: surgical technique. Otol Neurotol. 2002;23(5):704-709.

Tyler RS, Gantz BJ, Rubinstein JT, et al. Three-month results with bilateral cochlear implants. Ear Hear. 2002;23(1 suppl):80S-89S.

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Coding

CPT Procedure Code Number(s)
69930, 92601, 92602, 92603, 92604, 92626, 92627, 92630, 92633
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
MEDICALLY NECESSARY

H90.3 Sensorineural hearing loss, bilateral

H90.6 Mixed conductive and sensorineural hearing loss, bilateral


EXPERIMENTAL/INVESTIGATIONAL

H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side

H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side

H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side

H90.71 Mixed conductive and sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side

H90.72 Mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side
HCPCS Level II Code Number(s)
MEDICALLY NECESSARY

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

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

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

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 or auditory osseointegrated device speech processor, ear level, replacement, each

L8625 External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each

L8627 Cochlear implant, external speech processor, component, replacement

L8628 Cochlear implant, external controller component, replacement

L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement


THE FOLLOWING DEVICE IS COVERED ONLY WHEN THE MEMBER HAS A BENEFIT FOR HEARING AIDS:

V5273 Assistive listening device, for use with cochlear implant

Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

4/22/2024
4/22/2024
11.01.02
Medical Policy Bulletin
Commercial
No
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