Sunflower Health Plan Cochlear Implant Replacements (PDF) Form

This policy outlines medical necessity criteria for the replacement of cochlear implants and/or cochlear implant components. The cochlear implant has 4 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 external 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. A sound processor replacement if the current processor is at least five years old. 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 most often is caused by 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 higher hearing thresholds in the bilateral implants. Speech recognition scores in quiet and noisy Page 1 of 5 CLINICAL POLICY Cochlear Implant Replacements CEN"l'.'ENE" ~·orporatwn conditions were also improved in bilateral users. 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 6 months after the second implant was activated. However, performance showed a slight decline after 6 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 devises 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 2020, 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. CPT®* Codes 69949 Unlisted procedure, inner ear Headset/headpiece for use with cochlear implant device, replacement HCPCS Codes L8615 L8616 Microphone for use with cochlear implant device, replacement L8617 L8618 L6819 Transmitting coil for use with cochlear implant device, replacement Transmitter cable for use with cochlear implant device, replacement Cochlear implant, external speech processor and controller, integrated system, replacement Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement Alkaline battery for use with cochlear implant device, any size, replacement Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement Lithium ion battery for use with cochlear implant device speech- processor, ear level replacement, each L8621 L8622 L8623 L8624 Page 2 of 5 CLINICAL POLICY Cochlear Implant Replacements CEN"l'.'ENE" ~·orporatwn HCPCS Codes L8627 L8628 L8629 Cochlear implant, external speech processor, component, replacement Cochlear implant, external controller component, replacement Transmitting coil and cable, integrated, for use with cochlear implant device, replacement ICD-10-CM Diagnosis Codes that Support Coverage Criteria ICD 10 - - CM Code H90.3 H90.41 H90.42 H90.5 Q85.00 Q85.02 Z96.21 Sensorineural hearing loss, bilateral Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side Unspecified sensorineural hearing loss Neurofibromatosis, unspecified Neurofibromatosis, type 2 Cochlear implant status Reviews, Revisions, and Approvals Initial approval date Added criteria for replacement of implants and components Clarified policy language to discuss replacement of implants or components only Background updated Converted into new template Converted to new template. References reviewed. ICD 10 codes added. Clarified in II that replacements are not medically necessary when requested only for convenience/ to upgrade to newer technology. References reviewed and updated. References reviewed and updated. Added criteria for sound processor replacement if it is over 5 years old. Removed CPT 69717and 69718 and replaced with CPT 69949 References reviewed and updated. Codes review. References reviewed and updated. Annual review. References reviewed and updated. Coding reviewed, added codes L8621 and L8622. Replaced all instance of “member” with “member/enrollee.” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Sent for specialist review. Annual review completed. Removed “or” in I.A. and I.B. Background updated with no impact to criteria. References reviewed and updated. Revision Date 06/13 09/14 Approval Date 02/09 06/13 09/14 09/15 09/15 09/16 09/17 09/16 09/17 07/18 10/18 06/19 06/19 06/20 07/21 07/18 10/18 07/19 07/20 07/21 07/22 07/22 Page 3 of 5