L8619, Cochlear implant, external speech processor and controller, integrated system,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Physician certification is required for coverage documenting that the component is ineffective for ADLs, that a medical-condition change necessitates a different component, or that the component reached reasonable useful life.
- For repairs, include original purchase date of the item repaired, the reason for repair/replacement, identification of the item and parts repaired, functionality status, and the manufacturer invoice cost.
- When billing replacements include original purchase date, last replacement date of the item billed, and reason for replacement.
- For exceptions to battery or other limits, submit a narrative in item #19 of the electronic 5010 claim form or an attachment for paper claims.
Key Coverage Criteria
- Replacement of an existing cochlear implant external component is covered when a physician certifies the existing component is ineffective to the point of interfering with activities of daily living.
- Replacement is covered when a change in the patient's medical condition necessitates a different type of external cochlear implant component as certified by a physician.
- Replacement is covered when the existing external component has reached its reasonable useful life; the reasonable useful life of a sound processor is not less than 5 years.
- Cochlear implantation is considered medically necessary whenbothcriterion 1andcriterion 2 listed below are met:The individual meetsAllthe following criteria (a through c):Has received limited benefit from conventional hearing aids;andIs able to participate* in a post-cochlear implant rehabilitation program;andAbsence of any of the following (i through iv):Active middle ear infections;orLesions in the auditory nerve; orLesions in the central auditory pathway;orAuditory neuropathy spectrum disorde [...]
- The individual meetsAllthe following criteria (a through c):Has received limited benefit from conventional hearing aids;andIs able to participate* in a post-cochlear implant rehabilitation program;andAbsence of any of the following (i through iv):Active middle ear infections;orLesions in the auditory nerve; orLesions in the central auditory pathway;orAuditory neuropathy spectrum disorders.*Note: For a young child, a parent or guardian may act as the surrogate for participation.and
- Has received limited benefit from conventional hearing aids;and
7 Active Policies
ANTHEM-CG-SURG-81, CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
A53708, Billing and Coding: External Components for Cochlear Implants
UHC-POL-cochlear-implants, Cochlear Implants
AMBETTER-CP.MP.14, Cochlear Implant Replacements
REGENCE-SUR08, Cochlear Implant
Related Codes
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