69930
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
17.29
Facility
$1059.81
Non-Facility
$1059.81
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Treatments tried, failed, or contraindicated; include the dates, duration, and reason for discontinuation.
- All recent applicable imaging studies and diagnostic tests.
- Documentation sufficient to demonstrate that the member meets the InterQual® CP: Procedures, Cochlear Implantation (adult) or InterQual® CP: Procedures, Cochlear Implantation (Pediatric) clinical coverage criteria, as applicable.
Key Coverage Criteria
- Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral sensorineural and/or for single sided or asymmetric Sensorineural Hearing Loss in adults ages 18 and older. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Cochlear Implantation.
- Non-hybrid cochlear implantation is proven and medically necessary under certain circumstances for bilateral Sensorineural Hearing Loss in children ages 6 months or older and for single-sided or asymmetric Sensorineural Hearing Loss in children ages 9 months or older. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Cochlear Implantation (Pediatric).
- Hybrid cochlear implantation is proven and medically necessary under certain circumstances for Sensorineural Hearing Loss in adults ages 18 and older. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures, Cochlear Implantation.
- Intraoperative EMG monitoring of the facial nerve during surgery for cholesteatoma, including mastoidotomy or mastoidectomy
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "H93.3x1 - H93.3x9" Disorders of acoustic nerve [compression].
- ICD-10 codes covered if selection criteria are met for intraoperative SEPs (as listed): "I06.0 - I06.9" Diseases of aortic valve.
7 Active Policies
AETNA-CPB-0406 — Tinnitus Treatments
UMR-POL-UMR-cochlear-implants — Cochlear Implants
SUREST-POL-SUREST-cochlear-implants — Cochlear Implants
UHC-POL-cochlear-implants — Cochlear Implants
AETNA-CPB-0514 — Meniere's Disease and Related Disorders: Surgery
Related Codes
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