February 16, 2010 Bottom Line

Cochlear Implant Coding

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
disorder; individual

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.

Steven C. White, PhD, CCC-A, director of health care economics and advocacy, can be reached at swhite@asha.org.

cite as: White, S. C. (2010, February 16). Cochlear Implant Coding. The ASHA Leader.

Cochlear Implant Coverage: Policies of Two Major Insurance Carriers

Two major carriers, Aeta and Cigna, have extensive policies on CI coverage.

Aetna

Aetna considers uniaural (monaural) or binaural (bilateral) cochlear implantation a medically necessary prosthetic for adults aged 18 years and older with bilateral, pre- or post-linguistic, sensorineural, moderate-to-profound hearing impairment. Aetna"s eligibility requires that adults have bilateral severe to profound sensorineural hearing loss determined by a pure tone average of 70 dB or greater at 500 Hz, 1000 Hz, and 2000 Hz and limited benefit from appropriately fitted hearing aids. (Limited benefit is defined by test scores of 40% correct or less in best-aided listening condition on open-set sentence cognition.)

Aetna considers uniaural or binaural cochlear implantation a medically necessary prosthetic for children 12 months of age or older with bilateral sensorineural hearing impairment who meet all of three criteria: 1) profound, bilateral sensorineural hearing loss determined by a pure tone average of 90 dB or greater at 500, 1000, and 2000 Hz; 2) limited benefit from appropriately fitted binaural hearing aids (with different definitions of "limited benefit" for children 4 years of age or younger and those older than 4 years); and 3) a 3- to 6-month hearing aid trial. This last requirement may be waived if there is radiological evidence of cochlear ossification.

Aetna's follow-up services are remarkable for audiologists and speech-language pathologists. All of the following additional medical necessity criteria also must be met for uniaural or binaural cochlear implantation in adults and children:

  • No medical contraindications to cochlear implantation.
  • Assessment by an audiologist and an otolaryngologist experienced in this
    procedure indicating the likelihood of success with a cochlear implant.
  • Enrollment in an educational program that supports listening and speaking with aided hearing.
  • Arrangements for appropriate follow-up care including long-term speech-language treatment to take full advantage of this device.

Cigna

Cigna (search "cochlear implants") covers unilateral or bilateral cochlear implants as medically necessary for individuals with bilateral sensorineural hearing loss when there is reasonable expectation that a significant benefit will be achieved from the device and when age-specific criteria are met.

Adults (age 18 or older) must have both bilateral, severe-to-profound sensorineural hearing loss determined by a pure-tone average of 70 dB hearing loss or greater at 500 Hz, 1000 Hz and 2000 Hz and limited or no benefit from appropriately fitted hearing aids.

Children (age 12 months to 17 years, 11 months) must have both profound, bilateral sensorineural hearing loss with thresholds of 90 dB or greater at 1000 Hz and limited or no benefit from a three-month trial of appropriately fitted binaural hearing aids.

Cigna further states that aural rehabilitation following device implantation is an integral part of the overall management of cochlear implant in both adults and children, and calls for an aural rehabilitation program for implant programming of six to 10 sessions for both adults and children. Under Cigna, auditory and speech-language treatment may be considered rehabilitative therapy, and are typically independent of the aural rehabilitation.



  

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