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2.2.5.1.1 Prior Authorization Requirements for Cochlear Implants
Prior authorization is required for the cochlear implant surgery, device, and replacement parts. Documentation submitted for review must indicate who will be providing the cochlear implant device (i.e., the facility or the DME/medical supplier). The National Provider Identifier (NPI) or Texas Provider Identifier (TPI) of the supplier of the device must be included on the prior authorization request.
Prior authorization for a unilateral or bilateral cochlear implant may be granted for clients who are 12 months of age or older with documentation of all of the following criteria:
• Cognitive ability to use auditory cues and written documentation of agreement by the client or the client's parent or guardian that the client will participate in a program of post-implantation aural rehabilitation. This documentation must be maintained in the client's medical record.
•Postlingual deafness or prelingual deafness.
•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.
•Diagnosis of severe-to-profound bilateral sensorineural hearing loss with documentation of poor speech discrimination and a recommendation for cochlear implant candidacy.
•Inability to derive benefit from appropriately fitted hearing aid devices.
Covered diagnosis codes are limited to the following:
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