Cochlear Implants BAHA (Bone-Anchored Hearing Aid) ABI (Auditory Brainstem Implant) Bone-Conduction Hearing Aid Form

1 Cochlear Implants BAHA (Bone-Anchored Hearing Aid) ABI (Auditory Brainstem Implant) Bone-Conduction Hearing Aid Medical Policy Updated Revision Effective: February 1st, 2026 Policy Number: UM201POL Approval Date: Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy) Description Cochlear implants are surgically implanted as a prosthetic device that uses electrical stimulation to produce hearing in the treatment of bilateral sensorineural hearing impairment. Implant can provide member with improved speech and hearing communication abilities. Implant is surgically placed under the skin, behind the ear. Implant consists of four parts: 1. Microphone: picks up sounds from the environment 2. Speech processor: externally worn or can be carried, it arranges the sound that is received via the microphone 3. Receiver/stimulator: receives the signals from speech processor and converts the signals into electrical impulses 4. Electrodes: collect the impulses and send to the brain Hybrid cochlear implants are surgically implanted devices with an external sound processor that works with the cochlear implant portion of the device and serves as a hearing aid for low-frequency hearing loss. BAHAs (bone-anchored hearing aids) are surgically implanted devices that transmit sound directly to the inner ear by going through the mastoid bone, bypassing external auditory canal and middle ear. Non-implantable bone-conduction hearing aids utilizing a headband or adhesive are used in various cases such as unilateral conductive, mixed or sensorineural hearing loss. In cases of conductive hearing loss, e.g., those resulting from the congenital malformation of the external ear canal, pinna and middle ear structures, it has utility where the use of air-conduction hearing aids (ACHAs) is not possible. These bone-conduction hearing aids may be held in place by a headband or adhesive, with the amplified vibrational sound transmitted transcutaneous to the bones of the skull for transmission to the cochlea. In this application there is no implantation surgery; rather, the sound processor is attached firmly to the head using either a hard or soft headband or adhesive, and the 11/11/2025

2 amplified vibrational sound is transmitted transcutaneous to the bones of the skull for transmission to the cochlea.
Children may use a headband or adhesive until their temporal bone is mature enough for implantation of a bone- anchored hearing aid. For adults, a headband or adhesive is often used to determine whether they might benefit from bone-anchored implant systems.

Auditory brainstem implant (ABI) is for people with hearing loss who cannot benefit from a hearing aid or cochlear implant. Used when there is an absent or very small hearing nerve or severely abnormal inner ear (cochlea). ABI directly stimulates the hearing pathways in the brainstem by bypassing the inner ear and the hearing nerve. Bone-conduction hearing aids are used for certain patients who are unable to benefit from standard air- conduction hearing devices (a conventional hearing aid) and may benefit from a device that transmits sound directly through the skull to the functioning cochleae (or cochlea, in the case of single-sided deafness). Bone- conduction hearing aids can be held against the skull with a steel-spring headband; however, this is typically painful, cumbersome, produces skull deformities, and does not achieve good-quality hearing.

 Line of Business

Commercial:

• HNE has adopted InterQual* criteria for the following procedures:
o Cochlear Implantation: CP:Procedures, Cochlear Implantation. o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Cochlear Implantation External Component Replacement. o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Cochlear Implantation Internal Component Replacement. o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Unilateral Hybrid Cochlear Implantation. o Cochlear Implantation, Pediatric: CP:Procedures, Cochlear Implantation (Pediatric). o Cochlear Implantation, Pediatric: CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) External Component Replacement o Cochlear Implantation, Pediatric: CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) Internal Component Replacement o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Anchored Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device Internal Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Anchored Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) Internal Component Replacement.

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• Refer to criteria under Policy section in this medical policy for the following procedures: o Non-Osseo integrated Hearing Devices. o Auditory Brainstem Implant (ABI), unilateral.

Medicaid – BeHealthy:

• HNE has adopted InterQual* criteria for the following procedures: o Cochlear Implantation: CP:Procedures, Cochlear Implantation. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Anchored Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device Internal Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Anchored Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) Internal Component Replacement.

• Refer to criteria under Policy section in this medical policy for the following procedures:
o Non-osseointegrated Hearing Devices. o Auditory Brainstem Implant (ABI), unilateral.

• Coverage for repair and replacement is outlined in 130 CMR 426.000: Audiologist Manual, Subchapter IV:
o Processor §426.408(C) o External components §426.416(K) https://www.mass.gov/lists/audiologist-manual-for-masshealth-providers

Medicare:

• HNE has adopted InterQual* criteria for the following procedures:
o Cochlear Implantation: CP:Procedures, Cochlear Implantation.
o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Cochlear Implantation External Component Replacement. o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Cochlear Implantation Internal Component Replacement. o Cochlear Implantation: CP:Procedures, Cochlear Implantation, Unilateral Hybrid Cochlear Implantation. o Cochlear Implantation, Pediatric: CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) External Component Replacement

4 o Cochlear Implantation, Pediatric: CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) Internal Component Replacement o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Anchored Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device Internal Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Anchored Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) Internal Component Replacement.

• Refer to criteria under Policy section in this medical policy for the following procedures:
o Non-Osseo integrated Hearing Devices. o Auditory Brainstem Implant (ABI), unilateral.

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Policy

I. Cochlear Implant

A. HNE has adopted following InterQual criteria.

• Sequential Bilateral Cochlear Implantation, Simultaneous Bilateral Cochlear Implantation, Unilateral Cochlear Implantation, Unilateral Hybrid Cochlear Implantation, for ages 18 years and older.

o CP:Procedures, Cochlear Implantation. o CP:Procedures, Cochlear Implantation, Cochlear Implantation External Component Replacement. o CP:Procedures, Cochlear Implantation, Cochlear Implantation Internal Component Replacement. o CP:Procedures, Cochlear Implantation, Unilateral Hybrid Cochlear Implantation.

• Sequential Bilateral Cochlear Implantation, Simultaneous Bilateral Cochlear Implantation, Unilateral Cochlear Implantation, for ages under 18 years.

o CP:Procedures, Cochlear Implantation (Pediatric). o CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) External Component Replacement o CP:Procedures, Cochlear Implantation (Pediatric), Cochlear Implantation (Pediatric) Internal Component Replacement

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B. Unilateral Hybrid Cochlear Implantation for under 18 years of age will be reviewed on a case-by-case basis.

C. Cochlear Implant for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

II. Bone-Anchored Hearing Aids (BAHA) and Bone Conducting Hearing Aids

A. HNE has adopted following InterQual criteria.

• Unilateral Percutaneous Bone Anchored Hearing Device, Bilateral Percutaneous Bone Anchored Hearing Device, Unilateral Transcutaneous Bone Conduction Hearing Device, Bilateral Transcutaneous Bone Conduction Hearing Device, Unilateral Osseointegrated Implant, Bilateral Osseointegrated Implant, for ages 18 years and older.

o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Anchored Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction, Bone Conduction Hearing Device Internal Component Replacement.

• Unilateral Percutaneous Bone Anchored Hearing Device, Bilateral Percutaneous Bone Anchored Hearing Device, Unilateral Transcutaneous Bone Conduction Hearing Device, Bilateral Transcutaneous Bone Conduction Hearing Device, Unilateral Osseointegrated Implant, Bilateral Osseointegrated Implant, for ages under 18 years.

o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Anchored Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric). o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) External Component Replacement. o Hearing Device, Bone Anchored or Bone Conduction, Pediatric: CP:Procedures, Hearing Device, Bone Anchored or Bone Conduction (Pediatric), Bone Conduction Hearing Device (Pediatric) Internal Component Replacement.

B. Bone-Anchored Hearing Aids (BAHA) and Bone Conducting Hearing Aids for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

6 III. Non-osseointegrated Hearing Devices (e.g., BAHA Soft Band, BAHA SoundArc, MED-EL Adhear, SoundBite) (not covered under plans that exclude coverage of hearing aids)

A. Covered by HNE as a bridge to an implantable BAHA for young children (less than 5 years of age) with conductive or mixed conductive and sensorineural hearing loss who meet medical necessity criteria for a BAHA in (II) above.

B. HNE covers members over 6-years old who are unable to benefit from a standard air-conduction device who have hearing aid coverage under their plan.

IV. Auditory Brainstem Implant (ABI), unilateral

A. Auditory Brainstem Implant is covered for ages 12 years or older when:

• Members have lost both auditory nerves due to disease (i.e., neurofibromatosis type 2 or von Recklinghausen’s disease) OR

• Individual undergoing bilateral removal of tumors of auditory nerves and it is anticipated that
the individual will become completely deaf.

B. Auditory Brainstem Implant for all other indications other than in criteria above is considered NOT MEDICALLY NECESSARY.

V. Not Medically Necessary

A. 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.

B. 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.

VI. Experimental and Investigational:

A. Cochlear Implants, BAHA, ABI and Bone-Conduction Hearing Aid are considered EXPERIMENTAL and INVESTIGATIONAL if above criteria are not met and also in the following situations:

1. Cochlear implants for auditory nerve agenesis.
2. Auditory Brainstem Implants for congenital deafness and tinnitus.
3. Bilateral use of an auditory brainstem implant.
4. Cochlear implantation as a treatment for patients with tinnitus.

5. Implantable BAHA for conductive or mixed hearing loss when criteria are not met because of insufficient evidence in the peer-reviewed published medical literature.

6. The use of an implantable BAHA for bilateral pure sensorineural hearing loss and for indications other than the ones included in criteria have not been established.

   B. Semi-implantable (e.g. Vibrant Soundbridge and the SOUNDTEC Maxum System) and fully implantable middle ear hearing devices (e.g. Esteem Implantable Hearing System) are considered EXPERIMENTAL and INVESTIGATIONAL.

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Policy Guidelines and Definitions

• Unilateral Hearing Loss (UHL): Hearing is normal in one ear with hearing loss in the other ear. Hearing loss can range from mild to very severe. Possible causes include family history; illness or infections; head injury; exposure to loud noises; outer, middle or inner ear abnormalities and some syndromes. Hearing loss can occur in children and adults.

• Single-Sided Deafness (SSD) is a form of UHL where there is no usable hearing in the impaired ear.

• Sensorineural: Hearing loss caused by a disease or lesion of the middle ear or the auditory nerve.

Coding Guidance

Code
Description Prior Authorization HCPCS BAHA DME: L8690 Auditory Osseo integrated device, includes all internal and external components Yes L8691 Auditory Osseo integrated device, external sound processor, replacement Yes L8692 Auditory Osseo integrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment Yes Cochlear DME: L8614 Cochlear Device/System, includes all internal and external components Yes L8615 Headset/headpiece for use with cochlear implant device replacement Yes L8616 Microphone for use with cochlear implant device, replacement

            Yes

L8619 Cochlear implant external speech processor, and controller, integrated system, replacement Yes L8627 Cochlear implant, external speech processor, component, replacement Yes L8628 Cochlear implant, external controller component, replacement

            Yes

L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement Yes Miscellaneous Codes: L8699 Prosthetic Implant, not otherwise specified. Yes CPT CODES 0951T Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor

Experimental/ Investigational (Auth not required) 0952T Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor 0953T Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor

8 Code
Description Prior Authorization 0954T Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers 0955T Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components 69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone Yes 69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone Yes 69714 Implantation, Osseointegrated implant, skull; with percutaneous attachment to external speech processor Yes 69716 Implantation, osseointegrated implant in skull; within mastoid with magnetic transcutaneous attachment to external speech processor Yes 69717 Replacement of cochlear stimulating system in skull with attachment through skin to external speech processor, AND Bone anchored revision or replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor. Yes 69719 Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex. Yes 69726 Removal, entire osseointegrated implant, skull; with percutaneous attachment to external speech processor Yes 69727 Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, within the mastoid and/or involving a bony defect less than 100 sq mm surface area of bone deep to the outer cranial cortex Yes 69728 Removal, entire osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex Yes 69729 Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex. Yes 69730 Replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside the mastoid and involving a bony defect greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex. Yes 69930 Cochlear device implantation, with or without mastoidectomy Yes CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

9 References

• MassHealth Guidelines for Medical Necessity Determination for Cochlear Implantation. https://www.mass.gov/lists/masshealth-guidelines-for-medical-necessity-determination

• National Coverage Determination (NCD) 50.3, Cochlear Implantation. NCD - Cochlear Implantation (50.3)

• Amonoo-Kuofi et al., Int J Pediatr Otorhinolaryngol 2015, 79:474-80

• Eshraghi, A. A., Nazarian, R., & Na, F. F. (2012, October 8). The cochlear implant: Historical aspects and future prospects.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921065/ PMID: 23044644

• Audiology online: Unilateral Hearing Loss in Children: Impact and Solutions. https://www.audiologyonline.com/articles/unilateral-hearing-loss-in-children-19953

• Victory, J, Hearing loss in one ear, Healthy Hearing. https://www.healthyhearing.com/report/52008-Living-in-the-head-shadow-of-single-sided- deafness

• Lin et al. Cochlear Implantation Outcomes in Patients with Auditory Neuropathy Spectrum Disorder of Genetic and Non-Genetic Etiologies: A Multicenter Study. Cochlear Implantation Outcomes in Patients with Auditory Neuropathy Spectrum Disorder of Genetic and Non-Genetic Etiologies: A Multicenter Study - PMC

• Alzhrani et al. Auditory and speech performance in cochlear implanted ANSD children. Auditory and speech performance in cochlear implanted ANSD children - PubMed

• ASHA Evidence Maps. Auditory Neuropathy Spectrum Disorder (ANSD). Auditory Neuropathy Spectrum Disorder (ANSD)

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 8/14/2001 Policy effective 10/2022 Medicare has made changes in the cochlear implant NCD effective 9/26/2022.
https://www.cms.gov/medicare-coverage-database/view/ncacal-decision- memo.aspx?proposed=N&ncaid=306 1/1/2023 Updated description for 69716, 69717, 69719, added codes 69729, 69730

10 Date Update 7/1/2023 • Added L8690, L8691 and L8692 • CPT 69714 with updated description • Added 69726, 69727, 69728, 69710, 69711 to policy (PA required) 1/2024 • Added Line of Business section • Updated references 8/2024 • Transitioned to InterQual for all lines of business, except where there are MassHealth guidelines for Medicaid and NCD for Medicare. 8/2025 • Semi-implantable and fully implantable middle ear hearing devices are added to the EXPERIMENTAL and INVESTIGATIONAL list. 09/2025 • Auditory Neuropathy Spectrum Disorder/Auditory Neuropathy, removed from EXPERIMENTAL and INVESTIGATIONAL (E&I) list.
• Auditory nerve agenesis added to the E&I list. • References updated.

10/2025 • IQ for Cochlear Implantation adopted for Medicaid and Medicare line of business. • References updated.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.