Clinical Policy: Cochlear Implant Replacements Form

CENTENE
Corporation

Clinical Policy: Cochlear Implant Replacements
Reference Number: CP.MP.14
Date of Last Revision: 05/25

Revision Log
Coding Implications

See Important Reminder at the end of this policy for important regulatory and legal
information.

Description

This policy outlines medical necessity criteria for the replacement of cochlear implants and/or
cochlear implant components. The cochlear implant has four basic components: a microphone,
worn externally behind the ear, which picks up sounds; an external speech processor, which
converts sounds to electrical signals; a transmitter and receiver/stimulator, which forward the
signals; and implanted electrodes, which stimulate the fibers of the auditory nerve.⁶

Policy/Criteria

I. It is the policy of health plans affiliated with Centene Corporation® that replacement of a
cochlear implant(s) and/or its components (external speech processor, controller,
etc.) is considered medically necessary when any one of the following is present:
A. The existing device(s) is no longer functional and cannot be repaired;
B. A change in the member/enrollee’s condition makes the existing unit(s) inadequate for the
hearing-related activities of daily living and improvement is expected with a replacement
unit(s);
C. The existing component has reached the limit of its reasonable useful life. The reasonable
useful life of a sound processor is not less than five years.

II. It is the policy of health plans affiliated with Centene Corporation that replacement or
upgrade of an existing, properly functioning cochlear implant and/or its external components
(external speech processor, controller, etc.) is considered not medically necessary when
requested only for convenience or to simply upgrade to a newer technology.

Background

Sensorineural hearing loss, or nerve deafness, is a type of hearing loss that results from problems
with the inner ear, related to the cochlea, eighth nerve, internal auditory canal, or brain. A
common cause of hearing loss in adults is presbycusis, a progressive condition caused by the loss
of function of hair cells in the inner ear.⁷ Severe to profound hearing loss in children is most
often related to genetics, prenatal, perinatal, or postnatal causes.⁵ A cochlear implant, an
electronic device surgically placed under the skin, bypasses the hair cells and directly transmits
sounds through multiple electrodes, which stimulate the auditory nerve.⁷ Once the auditory nerve
is activated, signals are sent to the brain. The brain learns to recognize these signals and the
person experiences this as hearing.²

Cochlear implants have been studied since the 1950s and were approved by the FDA in adults in
the mid-1980s.²,⁵ National Institute of Health (NIH) scientists determined cochlear implants to be
cost beneficial.

Recent studies have been conducted evaluating the use of bilateral cochlear implants compared
to unilateral implants. Many of these studies have shown that children obtained significantly

CENTENE
Corporation

CLINICAL POLICY
Cochlear Implant Replacements

higher hearing thresholds in the bilateral implants. Speech recognition scores in noisy conditions
were also improved in bilateral users, while speech perception outcomes in quiet conditions were
mixed demonstrating differences for only two out of seven outcome measures.¹,⁸ Studies also
have shown better scores on sentence and word recognition tests for bilateral users.¹

Very little data has been published comparing differences between bilateral cochlear implants
and cochlear implant with a hearing aid on the opposite ear. One small study showed improved
localization abilities and speech perception scores for two former users of cochlear
implant/hearing aid within the first six months after the second implant was activated. However,
performance showed a slight decline after six months of use. Further studies are needed in this
area to determine efficacy for bilateral cochlear implants in adults.¹

While evidence is increasing regarding the use of bilateral implants, bilateral implantation is not
without problems. Limited nerve survival that remains may be asymmetrical, resulting in an
unnatural pattern of neural activity in stimulation with electrical pulses. This asynchronous
stimulation across devices might result in individual neural impulses which are unlikely to result
in useful cues related to interaural differences. Also, bilateral implantation doubles the risks
associated with surgical intervention and is very costly.²

Coding Implications

This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered
trademark of the American Medical Association. All CPT codes and descriptions are copyrighted
2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are
from the current manuals and those included herein are not intended to be all-inclusive and are
included for informational purposes only. Codes referenced in this clinical policy are for
informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.
Providers should reference the most up-to-date sources of professional coding guidance prior to
the submission of claims for reimbursement of covered services.

CENTENE
Corporation

CLINICAL POLICY
Cochlear Implant Replacements

2. United States Food and Drug Administration. Cochlear implants. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/ CochlearImplants/default.htm. Published February 3, 2022. Accessed April 4, 2025.
3. Yosefof E, Hilly O, Ulanovski D, Raveh E, Attias J, Sokolov M. Cochlear implant failure: diagnosis and treatment of soft failures. Acta Otorhinolaryngol Ital. 2021;41(6):566 to 571.
4. North HJD, Lloyd SKW. Hearing rehabilitation in neurofibromatosis type 2. Adv Otorhinolaryngol. 2018;81:93 to 104. doi:10.1159/000485526.
5. Year 2019 position statement: Principles and guidelines for early hearing detection and intervention programs. J Early Hear Detect Interv. 2019; 4(2):1 to 44.
6. Local coverage article: billing and coding: external components for cochlear implants (A53708). Centers for Medicare and Medicaid Services Web site. https://www.cms.gov/medicare-coverage-database/search.aspx?redirect=Y&from=Overview. Published October 1, 2015 (revised November 7, 2019). Accessed April 4, 2025.
7. Blevins NH. Presbycusis. UpToDate. www.uptodate.com. Updated December 10, 2024. Accessed April 4, 2025.
8. National Institute for Health and Care Excellence (NICE). Cochlear implants for children and adults with severe to profound deafness: Technology appraisal guidance [TA566]. Published March 7, 2019. https://www.nice.org.uk/guidance/ta566. Accessed April 4, 2025.

CENTENE
Corporation

CLINICAL POLICY
Cochlear Implant Replacements

doi:10.14639/0392-100X-N1583

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health program organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise

CENTENE
Corporation

CLINICAL POLICY
Cochlear Implant Replacements

professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

©2018 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation.

Page 5 of 5