Bilateral or unilateral cochlear implantation of a U.S. Food and Drug Administration (FDA)âapproved cochlear implant may be considered medically necessary in patients ages 12 months and older with bilateral severe-to-profound pre- or postlingual (sensorineural) hearing loss, defined as a hearing threshold pure-tone average of 70 dB hearing loss or greater at 500, 1000, and 2000 Hz, who have shown limited or no benefit from hearing aids.
Cochlear implantation as a treatment for patients with unilateral hearing loss with or without tinnitus is considered investigational.
Upgrades of an existing, functioning external system to achieve aesthetic improvement, such as smaller profile components or a switch from a body-worn, external sound processor to a behind-the-ear model, are considered investigational.
Replacement of internal and/or external components solely for the purpose of upgrading to a system with advanced technology or to a next-generation device is considered investigational.
Replacement of internal and/or external components is considered medically necessary only in a small subset of members who have inadequate response to existing component(s) to the point of interfering with the individual’s activities of daily living, or the component(s) is/are no longer functional and cannot be repaired. Copies of original medical records must be submitted either hard copy or electronically to support medical necessity.
Cochlear implantation with a hybrid cochlear implant/hearing aid device that includes the hearing aid integrated into the external sound processor of the cochlear implant (eg, the Nucleus® Hybrid™ L24 Cochlear Implant System) may be considered medically necessary for patients ages 18 years and older who meet all of the following criteria:
· Bilateral severe-to-profound high-frequency sensorineural hearing loss with residual low-frequency hearing sensitivity; AND
· Receive limited benefit from appropriately fit bilateral hearing aids; AND
· Have the following hearing thresholds:
o Low-frequency hearing thresholds no poorer than 60 dB hearing level up to and including 500 Hz (averaged over 125, 250, and 500 Hz) in the ear selected for implantation; AND
o Severe-to-profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz ≥75 dB hearing level) in the ear to be implanted; AND
o Moderately severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz ≥60 dB hearing level) in the contralateral ear; AND
o Aided consonant-nucleus-consonant word recognition score from 10% to 60% in the ear to be implanted in the preoperative aided condition and in the contralateral ear will be equal to or better than that of the ear to be implanted but not more than 80% correct.
