Surgery
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 CODES
69930, 90669, 90732, 92601
- 92604, 92626, 92627
2.0 HCPCS 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 (US) 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 intellectual disability, 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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