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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