92640
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.76
Facility
$75.15
Non-Facility
$106.21
Documentation Required
- Documentation of diagnosis of neurofibromatosis type 2 (NF2).
- Documentation of patient age (≥12 years).
- Surgical documentation if implant placed at time of tumor removal (first-side or second-side) as relevant to approval basis.
- Clinical or operative documentation confirming deafness following tumor removal.
Key Coverage Criteria
- Unilateral auditory brainstem implant using surface electrodes on the cochlear nuclei for patients age ≥12 with a diagnosis of neurofibromatosis type 2 (NF2) who have been rendered deaf due to bilateral resection of neurofibromas of the auditory nerve.
- Restoration of some hearing in patients with neurofibromatosis type 2 (NF2) who are deaf following bilateral removal of neurofibromas involving the auditory nerve.
- Auditory Brainstem Implant is indicated for individuals aged 12 years or older diagnosed with neurofibromatosis type 2 (NF2).
- FDA approval and efficacy data based on unilateral implantation performed at first-side or second-side tumor removal surgery.
- Auditory brainstem implant (ABI) for individuals who are deaf due to bilateral resection of neurofibromas of the auditory nerve as a treatment option alternative to observation alone.
- Observation alone is the current practice for decision-making about hearing restoration in individuals deaf due to bilateral resection of neurofibromas of the auditory nerve.
5 Active Policies
BCBSIL-SUR714.009 — Auditory Brainstem Implant
BCBSMT-SUR714.009 — Auditory Brainstem Implant
BCBSNM-SUR714.009 — Auditory Brainstem Implant
BCBSOK-SUR714.009 — Auditory Brainstem Implant
SUR714.009 — Auditory Brainstem Implant
Related Codes
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