Cochlear Implants

Cochlear Implants A. Medicaid covers for unilateral cochlear implantation when there is documentation that demonstrates the procedure is medically necessary and would be beneficial in reducing limitations of hearing impairment. B. The following must be documented by the surgeon and/or audiologist: 1. Severe to profound sensorineural hearing loss in both ears as defined by FDA criteria with a lack of benefit from a well-fitting aid, 2. Cognitive ability to use auditory clues, patient motivation and a willingness to undergo an extended program of rehabilitation, 3. Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system, 4. No contraindications to surgery, and 5. The device must be used in accordance with the FDA approved labeling. C. Documentation for children twelve (12) months of age to seventeen (17) years of age must include: 1. The onset of hearing impairment must have occurred during the pre-or post-linguistic period, and 2. Bilateral severe to profound sensorineural deafness must be demonstrated by the inability to improve on age-appropriate closed set word identification tasks with amplification, or lack of progress in auditory training. D. Documentation for adults eighteen (18) years of age and older must include: 1. The onset of hearing impairment must have occurred during the pre-linguistic, peri- linguistic, or post-linguistic period, and 2. Post-linguistic deafened adults must demonstrate current FDA guidelines on test scores on sentence recognition scores from tape-recorded tests in the beneficiary’s best listening condition. E. Medicaid covers bilateral cochlear implantation when there is documentation that demonstrates the procedure is medically necessary and would be beneficial in reducing limitations of hearing impairment. Bilateral cochlear implantation must meet all of the criteria for unilateral cochlear implantation, above, in addition to the following criteria and circumstances. F. Medicaid covers bilateral cochlear implants under two (2) different circumstances: 1. Simultaneous bilateral cochlear implants, and 2. Subsequent contralateral cochlear implantation in patients who have already received a previous unilateral cochlear implant. G. Simultaneous bilateral cochlear implants are covered for beneficiaries who: 1. Have significant deafness, caused by meningitis with subsequent risk for early cochlear ossification, and, in the opinion of the treating physician, are appropriate candidates for bilateral cochlear implantation for the syndrome of post-meningitis deafness prior to cochlear ossification, or 2. Pre-lingually deaf children with profound hearing loss, and who, in the opinion of the treating specialist physician, would benefit from the additional neuronal stimulation afforded by simultaneous bilateral cochlear implantation at an early age. Some patients in this category may, in the opinion of the treating specialist physician, benefit from a staged or subsequent contralateral cochlear implantation as opposed to a simultaneous implantation. H. Subsequent contralateral cochlear implantation are covered for beneficiaries who: 1. Have bilateral profound deafness that have fallen short of communication goals despite prior placement of a unilateral cochlear implant, and in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant, 2. Are prelingually deaf children with bilateral profound hearing loss who have had prior unilateral cochlear implantation and who, in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant, or 3. Have bilateral auditory neuropathy to the extent such that their cochlear function is structurally normal but who have abnormal findings on auditory brainstem response testing, and, in the opinion of the treating specialist physician, would substantially benefit from a subsequent contralateral cochlear implant. I. Medicaid does not cover for bilateral cochlear implantation, either as a simultaneous procedure or a subsequent contralateral implantation if, in the opinion of the treating physician, audiologist, or therapist, the beneficiary has sufficient limited hearing in the lesser affected ear either could either be: 1. Sufficiently augmented by a hearing aid to augment the opposite cochlear implant, or 2. Could later benefit from a future surgical or other medical intervention to improve the hearing in the non-implanted ear. J. Medicaid covers a subsequent contra-lateral cochlear implant procedure, the testing, services and procedures, to properly evaluate a beneficiary and address the proper post-operative care and therapy for a second cochlear implant, when the beneficiary already has a unilateral cochlear implant. K. Medicaid does not cover the cost of the cochlear implant device through the Durable Medical Equipment program. The cost of the device is covered by the usual reimbursement methodology for either inpatient or outpatient hospital services and must be billed by the hospital. Medicaid does not cover additional benefits for the device if the surgical procedure is performed in any other outpatient settings. L. Medicaid covers the repair and/or replacement of the cochlear implant external speech processor and other minor supplies including batteries, cords, battery charger, and headsets through the Durable Medical Equipment (DME) program. Medicaid covers these items for all beneficiaries by DME providers only. Medicaid requires prior approval for repairs or replacements of external implant parts. M. Medicaid requires documentation by the provider of rehabilitative services supporting medical necessity and must be retained in the beneficiary’s medical record.