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CMS Expands Eligibility Criteria for Cochlear Implants

Originally posted to the American Speech-Language-Hearing Association Headlines e-mail list on 4/10

The Centers for Medicare and Medicaid Services (CMS) issued a coverage decision on April 5, 2005 that will increase access to cochlear implants by expanding the eligibility criteria. Currently, Medicare covers cochlear implants when speech recognition scores are 30% or less. The decision referenced ASHA's recommendation that by adopting FDA's allowance of higher sentence recognition scores, more adults can benefit from cochlear implants. The coverage decision memo did not set an implementation date, however, it is expected that information on the effective date will be published within the next 30 days.

In its decision memo CMS states, The evidence is adequate to conclude that cochlear implantation is reasonable and necessary 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 40% and
This favorable Medicare eligibility ruling follows ASHA's successful advocacy efforts late last year that created a new Ambulatory Payment Classification (APC) for cochlear implant follow-up and programming, and significantly increased reimbursement for these procedures under the 2005 Hospital Outpatient Prospective Payment System (OPPS). ASHA's continued lobbying also helped to increase reimbursement rates for cochlear implantation by almost 15% for a median payment rate of $26,000.

The CMS decision memo on cochlear implant eligibility criteria can be found on the CMS Web site at http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=134 . For additional information, please contact Ingrida Lusis, ASHA's Director of Health Care Regulatory Advocacy, via email at ilusis@asha.org or by phone at 800-498-2071, ext. 4482.

Reprinted by permission of the American Speech-Language-Hearing Association

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