HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-67-017
Topic:
Cochlear Implantation
Section:
Surgery
Effective Date:
January 15, 2018
Issued Date:
October 8, 2018
Last Revision Date:
October 2018
Annual Review:
October 2018
 
 

A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture and amplify sound. Cochlear implant devices are available in single channel and multi-channel models. The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for persons who are profoundly hearing impaired.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Unilateral or bilateral cochlear implantation of a U.S. Food and Drug Administration (FDA) approved cochlear implant device may be considered medically necessary when ALL of the following criteria have been met: 

  1. Individuals greater than or equal to 12 months of age with bilateral severe to profound pre-or post-lingual (sensorineural) hearing loss defined as a hearing threshold of pure-tone average of 70 decibels (dB) hearing loss or greater at 500 hertz (Hz), 1,000 Hz, and 2,000 Hz, and have shown limited or no benefit from hearing aids. The age of the recipient at the time of implantation should  be consistent with the FDA guidelines for the specific implant used; and
  2. Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; and
  3. Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system; and
  4. No medical contraindications to cochlear implantation (including but not limited to active middle ear infection, deafness due to lesions of the eighth (8th) cranial nerve or brainstem, and absence of cochlear development). 

Bilateral cochlear implantation may be considered medically necessary when it has been determined that the alternative of unilateral cochlear implant plus hearing aid in the contralateral ear will not result in a binaural benefit; (i.e., in individuals with hearing loss of a magnitude where a hearing aid will not produce the required amplification.) 

In addition, auditory training and basic guidance (e.g., fitting external parts, programming the processor, etc.) performed during the postoperative period may be eligible for separate reimbursement when coverage for the cochlear implantation has been established. 

Cochlear implantation is considered not medically necessary when provided for any other diagnosis other than the conditions referenced above.

Cochlear implantation is considered experimental/investigational and, therefore, non-covered as a treatment for  individuals with unilateral hearing loss with or without tinnitus.  Scientific evidence does not support the use of cochlear implantation for unilateral hearing loss.

69930

92601

92602

92603

92604

92626

92627

92630

92633

L8614

L8615

L8616

L8617

L8618

L8619

L8621

L8622

L8623

L8624

L8625

L8627

L8628

L8629

L8699

 

 

 

 




Nucleus® Hybrid™ L24 Cochlear Implant System

Cochlear implantation with a hybrid cochlear implant/hearing aid device that includes the hearing aid integrated into the external sound processor of the cochlear implant (e.g., the Nucleus® Hybrid™ L24 Cochlear Implant System) may be considered medically necessary for individuals greater than or equal to 18 years  who meet ALL of the following criteria:

  • Bilateral severe-to-profound high-frequency sensorineural hearing loss with residual low-frequency hearing sensitivity; and
  • Receive limited benefit from appropriately fit bilateral hearing aids; and
  • Have the following hearing thresholds:
    • Low-frequency hearing thresholds no poorer than 60 dB hearing level up to and including 500 Hz (averaged over 125, 250, and 500 Hz) in the ear selected for implantation; and
    • Severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz greater than or equal to 75 dB hearing level) in the ear to be implanted; and
    • Moderately severe to profound mid- to high-frequency hearing loss (threshold average of 2000, 3000, and 4000 Hz greater than or equal to 60 dB hearing level) in the contralateral ear; and
    • Aided consonant-nucleus-consonant word recognition score from 10% to 60% in the ear to be implanted in the preoperative aided condition and in the contralateral ear will be equal to or greater than the ear to be implanted but not greater than 80% correct.

9930

92521

92522

92523

92524

92626

92627

92630

92633

L8614

L8615

L8616

L8617

L8618

L8619

L8621

L8622

L8623

L8624

L8625

L8627

L8628

L8629

L8699

 

 

 

 




The following codes may be used for diagnostic purposes to assist the physician in assessing the individual’s ability to utilize residual hearing to design a management plan, monitor progress and measure outcome of management. The testing can assist in obtaining information necessary for the physician's medical evaluation or to determine the appropriate medical or surgical treatment. Testing frequency depends on the needs of each individual. Testing frequency may range from a single visit to numerous depending on the severity of the problem, complexity of the management plan and the individual’s progress.

92626

92627




Professional Statements and Societal Positions Guidelines

Center for Disease Control (CDC) – 2002

Individuals with cochlear implants are more likely to develop bacterial meningitis than individuals without cochlear implants. The bacteria Streptococcus pneumoniae (pneumococcus) causes most cases of meningitis in individuals with cochlear implants. Due to increased risk, the CDC recommends age appropriate pneumococcal vaccination for individuals who have or are candidates for cochlear implants.


H90.3

H90.5

H90.6

H90.8

H90.A21

H90.A22

Z96.21



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Cochlear implantation is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.