01Billing team: For cochlear implant claims, keep documentation that the member had an assessment by an audiologist and by an otolaryngologist experienced in this procedure indicating the likelihood of success with the device, that the member has no medical contraindications to cochlear implantation, that the member and family have realistic expectations, that the member is enrolled in an educational program that supports listening and speaking with aided hearing, that follow-up care including long-term speech therapy is arranged, and that the member is current on age-appropriate pneumococcal vaccination (2 or more weeks before surgery when possible).
02The requirement for evaluation by a participating otolaryngologist and audiologist applies only to network plans, and all other plans require documentation of hearing loss that is likely to be improved with the implant.
03For adults and children, arrange a post-cochlear implant rehabilitation program, which the policy says is medically necessary to achieve benefit and usually consists of 6 to 10 sessions of about 2.5 hours each.
04Replacement of a cochlear implant or its external components is medically necessary when the existing device is not functional and cannot be repaired, or when a change in the member's condition makes the present unit non-functional and improvement is expected with a replacement unit.
05Recommended accessories and upgrades receive a separate medical necessity assessment, and upgrades to an existing speech processor or controller are not medically necessary when requested for convenience or aesthetics while the current components remain functional.
06For auditory brainstem implant claims, document that the member is 12 years of age or older and has lost both auditory nerves due to disease (such as neurofibromatosis or von Recklinghausen's disease), or that bilateral surgical removal of auditory nerve tumors is planned and is expected to result in complete bilateral deafness.
07Codes 92650 through 92653 are not covered for the indications listed in the policy.