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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 22.2
Cochlear Implantation
Issue Date:  March 2, 1988
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODES
69930, 90669, 90732, 92601 - 92604, 92626, 92627
2.0  HCPCS Procedure Codes
Level II Codes L8614 - L8624
3.0  DESCRIPTION
A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture and amplify sound. Cochlear implant devices are available in single channel and multi-channel models. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are hearing impaired.
4.0  POLICY
4.1  Cochlear implantation using a United States (U.S.) Food and Drug Administration (FDA) approved single or multichannel cochlear implant is a covered benefit when all of the following criteria are met:
4.1.1  The cochlear implant is used in accordance with FDA approved labeling for the specific device prescribed; and
4.1.2  The individual has had an assessment by an audiologist and from an otolaryngologist experienced in this procedure indicating the likelihood of success with this device; and
4.1.3  The individual has the cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation. A post-cochlear implant rehabilitation program is necessary to achieve benefit from the cochlear implant. The rehabilitation program consists of six to 10 sessions that last approximately 2.5 hours each. The rehabilitation program includes development of skills in understanding running speech, recognition of consonants and vowels, and tests of speech perception ability. See Chapter 7, Sections 7.1 and 18.1.
4.1.4  In addition to the above, the recipient of a cochlear implant should be up-to-date on age appropriate pneumococcal vaccination at least two weeks prior to the implant, in accordance with the Centers for Disease Control and Prevention (CDC).
4.2  Simultaneous or sequential bilateral cochlear implantation is a covered benefit for:
4.2.1  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. 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 (HINT) sentences).
4.2.2  Children with bilateral sensorineual hearing impairment who meet both of the following criteria:
4.2.2.1  Child has limited benefit from appropriately fitted binaural hearing aids. For children four 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 (MLNT)) in conjunction with appropriate amplification and participation in intensive aural habilitation over a three to six month period. For children older than four 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 HINT for children, the open-set MLNT or Lexical Neighborhood Text (LNT), depending on the child’s cognitive ability and linguistic skills; and
4.2.2.2  A three to six month hearing aid trial has been undertaken and failed by a child without previous experience with hearing aids.
4.3  Replacement of the cochlear implant external speech processor device is covered.
5.0  EXCLUSIONS
5.1  Cochlear implantation is contraindicated when preoperative radiographic evidence indicates an underdeveloped internal auditory canal, the absence of cochlear development or a physical condition which precludes placement of the electrode array or receiver-stimulator (e.g., cochlear ossification that prevents electrode insertion).
5.2  Cochlear implantation is contraindicated when there is a middle ear infection, the cochlear lumen is structurally unsuited to implantation, or there is a lesion in the auditor nerve or acoustic area of the central nervous system.
5.3  Cochlear implantation may not be cost-shared when there is a contraindication to surgery and implantation, such as poor anesthetic risk, severe mental retardation, severe psychiatric disorders, and organic brain syndrome.
6.0  Effective Dates
6.1  April 4, 2005.
6.2  July 27, 2012, for children under 12 months of age.
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