Point32 Commercial Clinical Policy

Point32 Cochlear Implants Form


Effective Date

04/01/2023

Last Reviewed

10/19/2022

Original Document

  Reference



Cochlear Implants

Cochlear implants are a device used for the treatment of severe-to-profound hearing loss in individuals who only receive limited benefit from amplification with hearing aids. A cochlear implant provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea.

Clinical Guideline Coverage Criteria

Cochlear implantation of a U.S. Food and Drug Administration (FDA) approved cochlear implant device may be medically necessary in patients aged nine (9) months and older when all of the following criteria are met:

  1. Patient has been diagnosed with one of the following:
    • Bilateral moderate-to-profound sensorineural hearing loss as defined by behavioral audiometric recorded word/sentence testing score (e.g., consonant-nucleus-consonant CNC) of less than or equal to 60% in the best aided binaural condition or Auditory Brainstem Response (ABR) hearing thresholds greater than or equal to 70 dB (decibels) hearing level at frequencies 1000, 2000, and 4000 Hz (Hertz) who have shown limited or no benefit from hearing aids OR
    • Unilateral Hearing Loss (UHL) as defined by an absence of usable hearing in one ear (recorded word/sentence testing score less than or equal to 40% or ABR thresholds greater than or equal to 70 dB at frequencies 1000, 2000, and 4000 Hz); and Normal to near-normal hearing in the contralateral ear or hearing loss that is treatable by hearing aid. This includes Single Sided Deafness (SSD).
  2. Inner ear anatomy is expected to support cochlear implantation
  3. None of the following contraindications are present:
    • Absent cochlear or known absent cochlear nerve such as post trauma or post-surgical, etc.
    • Major cochlear ossification defined as obliteration of both scala tympani and scala vestibuli in two or more turns of the cochlea
    • Otologic conditions in which surgery is contraindicated, such as
      • Active middle ear or mastoid infection
      • Tympanic membrane perforation
      • Any other contraindication
    • Evidence of retro cochlear pathology including but not limited to:
      • Brainstem lesions involving cochlear nucleus
      • Severe central auditory processing disorder
Codes
Want to learn more?