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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 3 Implantable Hearing Devices and Related Services : 3.2 Services, Benefits, Limitations and Prior Authorization : 3.2.1 Cochlear Implants : 3.2.1.1 Prior Authorization

3.2.1.1
Prior authorization is required for the following:
Requests for prior authorization must be submitted by the provider to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply.
Note:
Requests for clients who are 20 years of age or younger who do not meet the medical necessity criteria may be considered through Comprehensive Care Program (CCP).
Documentation submitted for review must indicate who will be providing the cochlear implant device (i.e., the facility or the Durable Medical Equipment (DME) or medical supplier). The supplier’s provider number 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 and 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 auditory rehabilitation. This documentation must be maintained in the client’s medical record.
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.
Documentation of poor speech discrimination and a recommendation for cochlear implant candidacy and the most appropriate ICD-10-CM diagnoses for severe-to-profound bilateral sensorineural hearing loss.
The initial lithium ion battery recharger unit, additional medically necessary units, and additional replacement batteries beyond the limitations indicated in the following sections may be reimbursed with prior authorization. Documentation must be submitted with the prior authorization request to support medical necessity for the request.
Refer to:
Subsection 3.2.4, “Sound Processor Replacement and Repair” in this handbook for more information about sound processor repair or replacement.

Texas Medicaid & Healthcare Partnership
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