L8627 — Cochlear implant, external speech processor, component, 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.
- Claims for CPT/HCPCS codes describing services on anatomic structures that can be distinguished as left or right must include the appropriate laterality modifier (-RT or -LT) on each claim line for unilateral procedures.
- Bilateral procedures must be indicated by the appropriate bilateral modifier (use the payer- or code-specific bilateral modifier rather than -RT/-LT).
- CPT codes whose descriptions explicitly state 'unilateral or bilateral' do not require additional laterality modifiers.
7 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
A56869 — Billing and Coding: Use of Laterality Modifiers
Related Codes
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