Implantation, to include the implants and the external speech processor device, is a covered benefit if:
- approved by the U.S. Food and Drug Administration (FDA),
- the implant is used for approved indications,
- the individual has had an assessment by an audiologist and an otolaryngologist with experience in this procedure indicating the likelihood of success with this device,
- cognitive ability is present to use auditory clues and a willingness to undergo an extended program of rehabilitation, and
- the beneficiary is up to date on age-appropriate pneumococcal vaccination at least two weeks prior to the implant, in accordance with the Centers of Disease Control and Prevention (CDC).
Simultaneous or sequential bilateral cochlear implantation is a covered benefit for:
- Adults aged 18 years and older with bilateral, pre- or post-linguistic, sensorineural, moderate to profound hearing impairment who have received limited benefit from appropriately fitted binaural hearing aids.
- Children with bilateral sensorineural hearing impairment who meet both of the following criteria:
- limited benefit from appropriately fitted binaural hearing aids, and
- a three to six month hearing aid trail has been undertaken and failed by a child without previous experience with hearing aids.
Cochlear implants are not covered if there is a contraindication for the surgery such as a middle ear infection, a lesion in the auditor nerve, poor anesthetic risk, severe mental retardation, severe psychiatric disorders, or organic brain syndrome. They are also excluded when there is an underdeveloped internal auditory canal, no cochlear development, or a physical condition which precludes placement of the electrode array or receiver-stimulator.
See also hearing aids.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Costs may include hospitalization and durable medical equipment.