L8619 — Cochlear implant, external speech processor and controller, integrated system, replacement
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.
- 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.
6 Active Policies
AMBETTER-CP.MP.14 — Cochlear Implant Replacements
UHC-POL-cochlear-implants — Cochlear Implants
ANTHEM-CG-SURG-81 — CG-SURG-81 Cochlear Implants and Auditory Brainstem Implants
A53708 — Billing and Coding: External Components for Cochlear Implants
UMR-POL-UMR-cochlear-implants — Cochlear Implants
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.