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Informational Bulletin 21-29: Cochlear Implant Policy

Date: 12/22/21

The Louisiana Department of Health issued Informational Bulletin 21-29: Cochlear Implant Policy. This update included revisions to the entire Cochlear Implant policy of the Professional Services section of the MCO Manual and is effective January 28, 2022.

Providers should review the entire policy in the MCO Manual for additional information.

The Cochlear Implant Policy covers the following information:

Louisiana Medicaid covers unilateral or bilateral cochlear implants when deemed medically necessary for the treatment of severe-to-profound, bilateral sensorineural hearing loss in beneficiaries under 21 years of age. Any implant must be used in accordance with Food and Drug Administration (FDA) guidelines.

Eligibility Criteria

A multidisciplinary implant team is to collaborate on determining eligibility and providing care and is to include, at minimum: a fellowship-trained pediatric otolaryngologist or fellowshiptrained otologist, an audiologist, and a speech-language pathologist.

An audiological evaluation must find:

  • Severe-to-profound hearing loss determined through the use of an age-appropriate combination of behavioral and physiological measures;
  • Limited or no functional benefit achieved after a sufficient trial of hearing aid amplification;

A medical evaluation must include:

  • Medical history;
  • Physical examination verifying the candidate has intact tympanic membrane(s), is free
  • of active ear disease, and has no contraindication for surgery under general anesthesia;
  • Verification of receipt of all recommended immunizations;
  • Verification of accessible cochlear anatomy that is suitable to implantation, as confirmed by imaging studies (computed tomography (CT) and/or magnetic resonance imagery (MRI)), when necessary; and
  • Verification of auditory nerve integrity, as confirmed by electrical promontory stimulation, when necessary.

For bilateral cochlear implants, an audiologic and medical evaluation must determine that a unilateral cochlear implant plus hearing aid in the contralateral ear will not result in binaural benefit for the beneficiary.

Non-audiological evaluations must include:

  • Speech and language evaluation to determine beneficiary’s level of communicative ability; and
  • Psychological and/or social work evaluation, as needed.

Pre-operative counseling must be provided to the beneficiary, if age appropriate, and the beneficiary’s caregiver must provide:

  • Information on implant components and function; risks, limitations, and potential benefits of implantation; the surgical procedure; and postoperative follow-up schedule;
  • Appropriate post-implant expectations, including being prepared and willing to participate in pre- and post- implant assessment and rehabilitation programs; and
  • Information about alternative communication methods to cochlear implants.

Prior Authorization and Reimbursement

All aspects of cochlear implant care (preoperative evaluation, implantation, implants, repairs, supplies, therapy) must be prior authorized, as specified below.

Preoperative Evaluation

The preoperative evaluation must be prior authorized through the submission of a PA-01 Form requesting approval as part of the implant team’s packet. After approval has been given and services provided, the appropriate team member shall bill the appropriate procedure code for the evaluation of speech, language, voice, communication, auditory processing, and/or audiologic/aural rehabilitation on a CMS-1500 claim form or electronically to receive reimbursement for the evaluation. This service is reimbursable for cochlear implant candidates although the beneficiary may not subsequently receive an implant.

Implants, Equipment, Repairs, and Replacements

At the time of surgery, reimbursement will be made to the hospital for both the implant and the per diem. Refer to Chapter 25, Hospital Services, for specific information. (See Appendix A for information on how to access other manual chapters)

For information on coverage of other necessary equipment, repairs, and replacements, please refer to Chapter 18, Durable Medical Equipment.

NOTE: Reimbursement for each implant will not be authorized until the surgical procedure has been approved.

Implantation Procedure

The cochlear implant surgery must be prior authorized. The surgeon shall submit a Request for Prior Authorization (PA-01 Form) as part of the implant team’s packet to the fiscal intermediary’s PA Unit requesting approval to perform the surgery. The PA must include documentation of supporting audiological, medical, and non-audiological evaluations, and documentation of preoperative counseling.

After approval and surgery, electronic or CMS 1500 claim submission of the appropriate procedure codes are billable by the surgeon and the assistant surgeon. This procedure shall not be billed as either team surgery or co-surgery. The surgeon’s claim form must have the PA number written in Item 23 (if billing hard copy). (See Appendix B for information on obtaining a PA-01 Form).

The assistant surgeon’s claim, if applicable, will pend to the Medical Review Unit and will be paid only if the surgeon’s request for implantation has been approved.

The anesthesiologist’s claim form does not require a PA number.

Postoperative Rehabilitative Costs

Only the audiologist will be reimbursed for the aural rehabilitation of the cochlear implant beneficiary after cochlear implant surgery. These procedures shall be billed electronically or on the CMS-1500 claim form and do not require PA.

Subsequent Speech, Language, and Hearing Therapy

Subsequent speech, language, and hearing therapy services for cochlear implant beneficiaries must be prior authorized. The request for PA should be submitted to the fiscal intermediary’s PA Unit on the PA-01 Form. (See Appendix B for information on accessing these forms).

Re-performance of the Implantation Surgery

Re-performance of cochlear implant surgery because of infection, extrusion, or other reasons must be prior authorized.

Documentation explaining the reason the initial cochlear implant surgery must be repeated and the request for re-performance should be submitted simultaneously to the PA Unit for review.

The PA number approving the re-performance must be on the claim form for reimbursement to be received.

Post-Operative Programming

Reimbursement is made for cochlear implant post-operative programming and diagnostic analysis services. Providers are to use the appropriate procedure code(s) for this service.