Several factors support coverage and payment for bilateral cochlear implants under Medicare. Cochlear implants are covered under the statutory Medicare benefit provision for prosthetic devices. Medicare has a longstanding national coverage policy providing coverage for cochlear implants when the patient meets the coverage criteria. The national coverage policy and coverage limitations do not address or distinguish unilateral versus bilateral cochlear implantation. Certain Medicare reimbursement rules, however, are complex, are subject to change, and may vary from carrier to carrier.
According to its most recent National Coverage Determination, Medicare provides coverage for cochlear implantation 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.
In the hospital outpatient setting, Ambulatory Payment Classification (APC) 0259 for cochlear implantation has a payment status indicator of T (Significant Procedure, Multiple Reduction Applies) that provides 100% of the APC payment rate for the first implant and 50% of the APC rate for the second implant. Again, Medicare coverage requirements must be met.
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