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).
4.3 Simultaneous or sequential
bilateral cochlear implantation is a covered benefit for:
4.3.1 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).
4.3.2 Children with bilateral sensorineual
hearing impairment who meet both of the following criteria:
4.3.2.1 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
4.3.2.2 A three to six month hearing
aid trial has been undertaken and failed by a child without previous
experience with hearing aids.