Cochlear implants (CIs) are an ever-evolving issue for audiologists. Children are identified with hearing loss at younger ages and new approaches to treating hearing loss are emerging, giving rise to more questions about how health plans (public and private) cover cochlear implants and related services.
Q: Does Medicare have a specific policy regarding cochlear implants?
Yes. An article in MLN Matters, a publication of the Centers for Medicare and Medicaid Services' (CMS) Medicare Learning Network, describes Medicare coverage for CI services that became effective April 4, 2005. The article can be accessed online [PDF] and states:
"CMS will cover treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss for individuals with hearing test scores equal to or less than 40% correct in the best aided listening condition on tape-recorded tests of open-set sentence recognition." More detailed coverage requirements are further listed in this article.
Additionally, CMS will cover cochlear implants of individuals with open-set sentence recognition test scores of greater than 40% to less than or equal to 60% correct, where the device was implanted in an acceptable clinical trial/study.
Q: Does Medicaid cover cochlear implants?
Medicaid coverage and payment for CIs and related services differs from state to state. The federal government provides general benefits category requirements for the states, including early and periodic screening, diagnosis and treatment (EPSDT), which requires coverage of services and related prosthetic devices and durable medical equipment for children. For adults, however, federal regulations give discretion to states for coverage of specific devices and services.
Q: Are private health plan policies uniform?
No. Each private health plan has its own approach to coverage (see "Cochlear Implant Coverage," p. 4); employers, of course, can modify their specific coverage even further. Therefore, regardless of the general policy of an individual patient's health insurance carrier, that individual's specific policy must be referenced to determine coverage.
Aduiologists and speech-language pathologists should be aware of state-mandated CI coverage. For example, in May 2009 Wisconsin become one of the first states to require insurance companies to cover the cost of CIs for children 18 years old or younger (The ASHA Leader, July 14, 2009).
Q: What are the Current Procedural Terminology® (CPT) codes for cochlear implant services?
CPT codes include:
92506, Evaluation of speech, language, voice, communication, and/or auditory processing
92507, Treatment of speech, language, voice, communication, and/or auditory processing
92601, Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming
92602, Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent programming
92603, Diagnostic analysis of cochlear implant, age 7 years or older; with programming
92604, Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming
92626, Evaluation of auditory rehabilitation status, first hour
92627, Evaluation of auditory rehabilitation status, each additional 15 minutes
92630, Auditory rehabilitation; pre-lingual hearing loss
92633, Auditory rehabilitation; post-lingual hearing loss
Q: What are the codes for cochlear implant services through the Healthcare Common Procedural Coding System (HCPCS)?
HCPCS codes include:
L8614, Cochlear Device/System
L8619, Cochlear implant external speech processor, replacement
L7500, Repair of prosthetic device, hourly rate (excludes V5335 repair of oral laryngeal prosthesis or artificial larynx)
L7510, Repair of prosthetic device, repair or replace minor parts
Providers should remember that Medicare restricts coverage of audiology services to diagnostic testing only. Medicare is also clear that SLPs must use CPT 92507 for treatment services, including auditory rehabilitation. Payers other than Medicare should accept all of the auditory rehabilitation codes.