Author Topic: Cochlear Implants  (Read 905 times)


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Cochlear Implants
« on: August 01, 2013, 10:15:49 AM »
Hopefully someone can help me with this. 

I am trying to help a gentleman get a second cochlear implant.  He has already had one ear done with a cochlear implant a couple years ago.  He has Medicare.  His clinic has told him that that he must make a down payment of $40,000 and they will reimburse if Medicare pays.  Of course this guy does not have $40K to hand over.  There is not much to be found on the CMS website regarding cochlear implants.  I found this information:

 Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set sentence cognition.Medicare coverage is provided only for those patients who meet all of the following selection guidelines.

Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from appropriate hearing (or vibrotactile) aids;
Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
No contraindications to surgery; and
The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.

I told him that I thought it was strange that a clinic which specializes in cochlear implants would not know whether or not it would be covered with Medicare.  I can understand a policy such as BCBS where benefits are different.  He said that his clinic as well as another clinic have told him that because of the "best-aided" verbiage that they say he has to have his cochlear implant on when testing.  We both disagree.  "Best-aided" refers to hearing aids not cochlear implants.  In the above policy information it even states limited benefit from amplification with appropriate hearing (or vibrotactile) aids.  Cochlear implants do not amplify sound.  Hearing aids do amplify the sound. 

I know how I would appeal this if Medicare denied payment, but he can't even get in the door to have the surgery without that outrageous down payment.  He says he has contacted Medicare but they have told him that if he fits the criteria they will pay.  He fits the criteria when he doesn't use his cochlear implant on the opposite side. As you can imagine, he is very frustrated.  Is there a way to get Medicare to do a predetermination of benefits?  If so, who would we contact? He lives in Minnesota. 

Here are the main codes that are used:
69930 Cochlear device implantation, with or without mastoidectomy
L8614 Cochlear Device/System

On a side note, I have worked in medical billing for many years.  Over the past 7, I have gradually lost my hearing.  I have moderate to profound hearing loss and speech recognition scores of 0% in each ear which makes it extremely difficult to talk on the phone.  I had to go through some extensive testing to see if I qualified for implants.  I qualified for cochlear implants (best-aided scores were 8% in my right and 19% in my left) and will be having both ears done on Aug 16.  I am so excited that I might be able to hear again.  The technology is amazing.  Although I have never billed for this type of service, I have experience from the other side so to speak.  :)

Any help would be appreciated.