V5273 — Assistive listening device, for use with cochlear implant
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
3 Active Policies
UHC-POL-cochlear-implants — Cochlear Implants
UMR-POL-UMR-cochlear-implants — Cochlear Implants
SUREST-POL-SUREST-cochlear-implants — Cochlear Implants
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.