BlueCross and BlueShield of Montana Medical Policy/Codes
Cochlear Implant
Chapter: Surgery: Procedures
Current Effective Date: December 27, 2013
Original Effective Date: April 13, 1994
Publish Date: September 27, 2013
Revised Dates: December 2009; December 2010; August 14, 2012; September 6, 2013
Description

A cochlear implant (CI) is a device for individuals with severe to profound hearing loss who only receive “limited benefit” from amplification with hearing aids. A cochlear implant provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea.

The FDA criteria elaborates to define “limited benefit” for adults by test scores of  60% or less in best-aided listening condition and 50% or less in the ear to be implanted on tape recorded tests of open-set sentence recognition when using hearing alone (e.g., Hearing in Noise Test sentences (HINT)).

For children less that five years of age, little or not benefit from hearing aids is demonstrated by a lack of progress in the development of simple auditory skills in conjunction with appropriate amplification and participation in an intensive auditory habilitation program over a three to six month period.  For children over the age of five years, minimal benefit from amplification is demonstrated by scores less than or equal to 30% correct on open-set word and phoneme speech recognition measures such as the Multi-Syllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT).

Severe hearing loss is defined as a bilateral hearing threshold of 70-85 decibels (dB) and profound hearing loss is defined as a bilateral hearing threshold of 90 dB and above.  Normal hearing is 0 - 19 dB.

The effectiveness of cochlear implants varies, with results ranging from the routine use of speech communication in some individuals to the use only as an aid in the practice of lip reading/speech reading for others.  For an overwhelming percentage of patients, some level of functioning is achieved that allows recognition of environmental sounds.

The basic components of a cochlear implant include:

  • Microphone;
  • External sound processor;
  • External transmitter;
  • Internal receiver implanted within the temporal bone;
  • Electrode array extends from the receiver into the cochlea.

Sounds that are picked up by the microphone are carried to the external sound processor, which transforms sound into coded signals.  These signals are transmitted transcutaneously to the internal receiver implanted in the temporal bone.  The receiver converts the incoming signal to electrical impulses that are then conveyed to the electrode array, ultimately resulting in stimulation of the auditory nerve. 

Currently three manufacturers have been approved by FDA to distribute cochlear implants in the U.S. They are:

  • Advanced Bionics
  • Cochlear Americas
  • MED-EL

Several cochlear implants are commercially available in the United States (U.S.): the Nucleus family of devices, manufactured by Cochlear Americas, the Clarion family of devices, manufactured by Advanced Bionics, and the Med El Combi 40+ device, manufactured by Med El Corporation.  Over the years, the FDA has approved subsequent generations of the various components of the devices, focusing on improved electrode design and speech-processing capabilities.  Furthermore, smaller devices and the accumulating data gained from experience in children have resulted in broadening of the selection criteria to include children as young as 12 months.  The labeled indications from the FDA for currently marketed arrays are summarized below.

FDA Approval Status of Currently Marketed Cochlear Electrodes

Clarion HiFocus

Nucleus 24

Nucleus 24 Contour

Med El Combi 40

Children 18 mo-7yr: Profound hearing loss

Children 18mo -24mo: Profound hearing loss

Children 12mo-2yr: Profound hearing loss

Children 18mo-18yr: Profound hearing loss

Adults: Post lingual - profound hearing loss

Older children 2-17yr:  Severe to profound hearing loss

Older children: Severe to profound hearing loss

Adults: Bilateral severe to profound hearing loss

 

Adults: Severe to profound loss pre and post lingual

Adults: Severe to profound loss pre and post lingual

 

The Clarion II Bionic Ear System is composed of a Clarion Hi Focus electrode in conjunction with a next generation internal transmitter.

Cochlear Hybrid™ (Cochlear, Inc.) is an electro-acoustic stimulation device currently undergoing clinical trials and as of November 2010 has not received FDA approval.

Next generation devices have typically offered a marginal improvement over previous devices, so that replacement of the internally implanted components is not routinely performed and thus may be considered medically necessary only in a small subset of patients who have an inadequate response to existing components. 

While cochlear implants have been used unilaterally in recent years, interest in bilateral cochlear implantation has arisen.  Benefits of bilateral cochlear implants are to improve understanding of speech in a noisy environment and localization of sound.  Improvements in speech intelligibility may occur with bilateral cochlear implants through binaural (listening with both ears) summation; i.e., signal processing of sound input from two sides may provide a better representation of sound and allow one to separate out noise from speech.  Speech intelligibility and localization of sound or spatial hearing may also be improved with head shadow and squelch effects, i.e., the ear that is closest to the noise will receive sound at a different frequency and with different intensity, allowing one to sort out noise and identify the direction of sound.  Bilateral cochlear implantation may be performed independently with separate implants and speech processors in each ear or with a single processor.  However, no single processor for bilateral cochlear implantation has been FDA approved in the United States.

A post-cochlear implant rehabilitation program is necessary to achieve benefit from the cochlear implant.  The rehabilitation program consists of 6 to 10 sessions that last approximately 2½ hours each.  The rehabilitation program includes development of skills in understanding running speech, recognition of consonants and vowels, and tests of speech perception ability.

Contraindications to cochlear implantation may include deafness due to lesions of the eighth cranial nerve or brain stem, chronic infections of the middle ear and mastoid cavity or tympanic membrane perforation.  The absence of cochlear development as demonstrated on computed tomography (CT) scans remains an absolute contraindication.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Medically Necessary

Blue Cross and Blue Shield of Montana (BCBSMT) may consider unilateral or bilateral cochlear implants (CI) and associated aural rehabilitation medically necessary if the patient meets ALL the following selection criteria:

  • One year or older with severe to profound pre or post lingual sensorineural hearing loss (defined as a hearing threshold of 70 decibels [dB] or above); AND
  • Limited benefit from hearing aids; AND
  • Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; AND
  • No contraindications to surgery (i.e., infection, cranial nerve can not be stimulated); AND
  • The device is used in accordance with U.S. Food and Drug Administration (FDA) approved labeling.

Upgrades of existing components may be considered medically necessary only for patients in whom response to existing components is inadequate to the point of interfering with the activities of daily living, or when components are no longer functional.

Exception to one year or older criterion noted above:

  • Bilateral cochlear implantation may be considered medically necessary in children less than one year of age who are deafened by bacterial meningitis and demonstrate onset of cochlear ossification based on an imaging study.
  • Unilateral cochlear implantation may be considered medically necessary in children less than one year of age who are diagnosed with profound deafness and meet the following criteria
    • diagnosis is confirmed by objective audiology measures such as an auditory brainstem response (ABR) or an auditory steady-state response (ASSR), AND
    • documentation that the child demonstrates lack of significant threshold improvement in the frequencies important for hearing spoken language when using appropriately fitted hearing aids, in conjunction with aural habilitation, for a minimum of three months.  Note:  The hearing aids the child uses during the hearing aid trial must be appropriate for optimal amplification of the child's degree of profound hearing loss.

Not Medically Necessary

BCBSMT considers upgrades of an existing, functioning external system to achieve aesthetic improvement, such as smaller profile components or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model not medically necessary. 

Rationale

Cochlear implants are recognized effective treatment of sensorineural deafness, as noted in a 1995 National Institutes of Health Consensus Department conference, which offered the following conclusions:

  • Cochlear implant has a profound impact on hearing and speech reception in post-lingually deafened adults with positive impacts on psychological and social functioning.
  • The results are more variable in children.  Benefits are not realized immediately but rather are manifested over time with some children continuing to show improvements over several years.
  • Prelinguistic deafened adults may also benefit, although to a lesser extent than postlingually deafened adults.  These individuals achieve minimal improvement in speech recognition skills.  However, other basic benefits, such as improved sound awareness, may meet safety needs.
  • Training and educational interventions are fundamental for optimal benefits.
  • Cochlear implants in children under two years old are complicated by the inability to perform detailed assessment of hearing and functional communication.  However, a younger age at implantation may limit the negative consequences of auditory deprivation and may allow more efficient acquisition of speech and language.  Some children with post meningitis hearing loss (under the age of two years) have received an implant due to the risk of new bone formation associated with meningitis, which may preclude a cochlear implant at a later date.                  

While use of a CI in one ear in patients with severe to profound hearing loss has become standard clinical practice, bilateral cochlear implants have been used rarely and primarily in research settings.  A review of the peer-reviewed literature in Medline from the period of 1995 through 2004 identifies only 13 case reports on patients with bilateral cochlear implants.  The case reports identified range in size from one to ten patients and most, but not all, patients reported slight to moderate improvements in sound localization and speech intelligibility with cochlear implant especially with noisy backgrounds but not necessarily in quiet environments.  When reported, the combined use of binaural stimulation improved hearing in the range of 1-4 decibels or 1% to 2%. While this improvement seems slight, any improvement in hearing can be considered beneficial in the deaf.

2006 Update

Over the past several years, an increasing number of prospective case series designed to assess whether bilateral cochlear implants can provide some of the benefits of binaural hearing have been published in peer reviewed literature.  These studies have assessed the benefits of bilateral CI on sound localization and speech perception in both adults and to a lesser extent in children.  Some of the largest and most complete of these case studies have been published during 2005 and 2006.  Most recently, Peters and colleagues presented at the American Otological Society meeting in May 2006 the largest U.S. case series to date of thirty children with sequentially placed cochlear implants. (Peters and colleagues, manuscript submitted for publication).  Thirty children, ages three years to thirteen years, were bilaterally implanted with sequential surgeries at least six months apart.  All patients received their first cochlear implant prior to five years of age and “possessed the necessary speech and cognitive skills to complete the speech tests”.  Other requirements for enrollment were based on speech measures obtained while the children were using the single implant.  These included MLNT (Multi-syllabic Lexical Neighborhood Test- children < 5 years) or LNT (Lexical Neighborhood Test – children  5 years),  score >30% at 70dB in the first implanted ear, severe to profound hearing loss in the second ear, participation in a rehabilitation program, and normal cochlear anatomy determined by radiographic studies

Children in this study acquired speech perception in the second ear within six months.  However, children under the age of eight years acquired perception in the second ear more rapidly and ultimately gained a higher level of speech understanding than older children.  These findings were felt to support the notion of a more “plastic” auditory system at a younger age.

In this study, speech perception testing in quiet and noise was performed preoperatively and again post activation at three, six and twelve months in both the unilateral and bilateral conditions.  Some older patients were also tested at twenty-four months.  The authors reported that sequentially implanted children of all age groups showed better mean speech perception scores in background noise in the bilateral condition than with one implant alone.  Speech performance in quiet was improved to a lesser degree, but this difference did not meet a level of statistical significance.  In younger children, speech perception scores improved for 12 months following the second implant while scores for older children plateaued at six months.  The rate of improvement in speech perception in the second ear was inversely related to the child’s age at the time of the second implant.

There appears to be growing consensus of support among experts in the fields of otolaryngology and speech development for the use of bilateral cochlear implants in both children and adults.  Bilateral implantation is being performed in a number of centers in the U.S. and there is extensive experience with the procedure in Europe as well, indicating the movement in clinical practice.

Both recent studies and recent developments in clinical practice suggest that in both adults and children bilateral CI will result in improvement in sound localization and result in improved speech perception in noise compared with unilateral CI.  While the analysis of bilateral CI continues, the recent new literature and developments in clinical practice are sufficient to support treating bilateral CI as medically necessary for certain patients. 

2008 Update

Literature review conducted through July 2008 identified a number of new studies that were relevant to this policy.  Sharma and Dorman report that central auditory pathways are “maximally plastic” for a period of about 3.5 years.  Stimulation delivered within this period result in auditory evoked potentials that reach normal values in three to six months.  However, when stimulation occurs after seven years, changes occur within one month, but then have little to no subsequent change. Sharma and Dorman also reported on auditory development in 23 children with unilateral or bilateral implants. In one child who received a bilateral device with later (after age 7) implantation of the second ear, the auditory responses in the second device were similar to that seen in “late-implanted” children.

Several studies have reported benefits for patients with a unilateral cochlear implant (CI) with hearing aid (HA) in the opposite ear (CI-HA).   Ching reported on 21 adults who used a unilateral cochlear implant and a contralateral hearing aid.  Binaural benefits were seen for at least one measure for their patients; measures included speech recognition, sound localization, and functional performance. Ching and colleagues subsequently reported on 29 children and 21 adults with unilateral cochlear implant and a contralateral hearing aid. They noted that both children and adults derived binaural advantages related to sentence perception in noise. Also, children and adults localized sound better with bilateral inputs. In another report, Holt concluded that children who used CI-HA benefited from combining the acoustic input, particularly in background noise.

A number of studies have also reported results with bilateral cochlear implants.  Litovsky reported that 9 of 13 (70%) children with bilateral cochlear implants discriminated source separations of <20 degrees and 7 of 9 performed better when using bilateral (vs. unilateral) devices.  Schoen and colleagues reported that bilateral cochlear implants were able to restore spatial hearing in 11 cochlear implant patients.  Litovsky and colleagues reported on a multicenter prospective study of 37 adults with post-linguistic bilateral hearing loss.  Bilateral benefit (speech understanding in quiet and noise) was seen in 32 of the 34 subjects.  The authors indicated that the 3dB improvement in signal to noise ratio noted in the study would result in an average improvement of 28% in speech understanding and that this improvement could be crucial. Questionnaire data (subjects used only the “best” unilateral device for three weeks) also indicated that bilateral users perceived their performance to be better than when using a single device. Ricketts and colleagues reported on 16 similar adults with postlinguistic bilateral hearing loss.  They found a small but significant advantage with bilateral implants for speech recognition in noise. While a training effect was noted over time for a subset of patients followed up to 17 months, a consistent bilateral advantage was noted. Ramsden and colleagues reported on 30 adults in England who had bilateral cochlear implants and received their second implant a mean of three years after the first.  At nine months, a significant (12.6%, p < 0.001) binaural advantage was seen for speech and noise from the front. They were not able to predict when the second ear would be the better performer. Sequential implantation with long delays between ears resulted in poor second ear performance for some of their subjects. Kuhn-Inacker reported on a group of 39 European children who had bilateral cochlear implants.  From qualitative and quantitative data, they concluded that bilateral implants improve the children’s communicative behavior, especially in complex listening situations.

The potential to restore cochlear function is not foreseeable in the near future (there is current research to restore hearing by stimulating cochlear hair cell regrowth), but destruction of the cochlea eliminates this possibility. However, if implantation of cochlear implants is believed to be most beneficial at a younger age, when the nervous system is “plastic,” this potential development seems too far in the future to benefit young children who are current candidates for a cochlear implant.

In summary, these studies show consistent improvement in speech reception (especially in noise) and in sound localization with bilateral devices. Studies also suggest that earlier implantation may be preferred. Based on these new studies, bilateral cochlear implants have been shown to provide important benefits.   In addition, a number of additional publications report on the benefits of bilateral cochlear implantation in both children and adults.  One study by Luntz reported results similar to those reported above, regarding the binaural benefits of unilateral cochlear implant and contralateral hearing aid.

2010 Update

A search of the MEDLINE database was performed for the period through November 2010.

The literature search identified: two technology assessments; one systematic review; one U.S. professional society guideline; one United Kingdom (UK) professional society position statement; and two review articles.

Bond et al. authored a technology assessment in the UK to investigate the clinical and cost-effectiveness of unilateral cochlear implants (using or not using hearing aids), and bilateral cochlear implants with a single cochlear implant (unilateral or unilateral plus hearing aid) for severely to profoundly deaf children and adults.  The clinical effectiveness review included 33 papers, of which two were randomized controlled trials [deaf children (n= 1,513) and adults (n= 1,379)].  They used 62 different outcome measures and overall evidence was of moderate to poor quality.  All studies in children comparing one cochlear implant with non-technological support or an acoustic hearing aid reported gains on all outcome measures.  Weak evidence shows greater gain from earlier implantation (prior to starting school).  The strongest evidence for an advantage from bilateral over unilateral implantation was for understanding speech in noisy conditions.  The comparison of bilateral with unilateral cochlear implants plus an acoustic hearing aid was limited by small sample sizes and poor reporting.  The authors concluded, “Unilateral cochlear implantation is safe and effective for adults and children and likely to be cost-effective in profoundly deaf adults and profoundly and prelingually deaf children.  There are likely to be overall additional benefits from bilateral implantation, enabling children and adults to hold conversations more easily in social situations.” 

In January 2009, the National Institute for Health and Clinical Excellence (NICE) released technology appraisal guidance 166, Cochlear implants for children and adults with severe to profound deafness.  The guidance includes the following recommendations:

  1. “Unilateral cochlear implantation is recommended as an option for people with severe to profound deafness who do not receive adequate benefit from acoustic hearing aids.
  2. Simultaneous bilateral cochlear implantation is recommended as an option for the following groups of people with severe to profound deafness who do not receive adequate benefit from acoustic hearing aids:
    • children, or
    • adults who are blind or who have other disabilities that increase their reliance on auditory stimuli as a primary sensory mechanism for spatial awareness.
  3. Sequential bilateral cochlear implantation is not recommended as an option for people with severe to profound deafness.
  4. For purposes of this guidance, severe to profound deafness is defined as hearing only sounds that are louder that 90 dB HL at frequencies of 2 and 4 k hertz (Hz) without acoustic hearing aids.  Adequate benefit from acoustic hearing aids is defined for this guidance as:
    • For adults, a score of 50% or greater on Bamford-Kowal-Bench (BKB) sentence testing at a sound intensity of 70 dB SPL.
    • For children, speech, language and listening skills appropriate to age, developmental stage and cognitive ability.
  5. Cochlear implantation should be considered for children and adults only after an assessment by a multidisciplinary team.  As part of the assessment children and adults should also have had a valid trial of an acoustic hearing aid for at least 3 months (unless contraindicated or inappropriate).”

Bilateral Stimulation

A review article by Firszt et al. evaluates the advantages of binaural hearing and the disadvantages of hearing with only one ear or hearing with two ears with significantly different sound thresholds.  A case study is presented that demonstrates the benefit of bimodal hearing (i.e., a cochlear implant [CI] in one ear and a contralateral hearing aid [HA]) in a nontraditional CI candidate with asymmetrical hearing thresholds.  Selected studies in adult recipients who use a CI and contralateral HA or who use two CIs are summarized.  The data overall demonstrates that bilateral CI recipients experience substantial binaural hearing advantages, including improved speech recognition in noise, localization, and functional everyday communication.  These results suggest that bilateral stimulation of the auditory system through a CI and contralateral HA or two CIs is beneficial.

Olson et al. conducted a systematic review to answer the clinical question: "Does amplification in the ear opposite of a cochlear implant provide improved communication function for adult users?"  Several trends about bimodal stimulation were observed, which include:

  • significantly better speech understanding in the bimodal condition for many participants;
  • in noise, the largest bimodal benefits in speech recognition;
  • variable findings on localization tasks; and
  • overall significant improvement in functional ability based on self-assessments.

The preponderance of evidence received grades of B or C.  The evidence available indicates "moderate" (II) strength in support of bimodal stimulation for adult implant users.  The authors noted that “additional research is needed about optimal time frame for introducing bimodal fittings as well as establishing a clinical profile of patients who may benefit most from this intervention compared to bilateral implantation.”

In May 2008, the British Cochlear Implant Group (BCIG) released a position paper on Bilateral Cochlear Implants.  The position paper includes the following regarding indications for use of bilateral implantation:

  • “For all profoundly deaf children in order to stimulate both auditory pathways and optimize speech, language and auditory development and maximize potential academic achievement.
  • For all profoundly deaf adults, unable to benefit from bimodal hearing;
  • For patients following meningitis or other risk of ossification, where failure to implant may result in obliteration or the cochlea, preventing future stimulation;
  • For patients with additional sensory handicap, where there is greater reliance on binaural hearing;
  • For patients who experience a loss of performance in the first implanted ear or loss of device function in the first ear but re-implantation in the same ear is contra-indicated;
  • For patients who agree to participate in research studies into bilateral implantation.”

Pediatrics

Jöhr et al. highlighted the surgical and anesthesiological considerations when performing cochlear implant surgery in very young infants (below one year of age).  This is an observational and literature review by pediatricians at a tertiary children’s hospital in Switzerland.  Patients younger than one year of age undergoing cochlear implant surgeries were analyzed concerning surgical techniques, and anesthesiological aspects of elective surgeries in small infants.  The results demonstrated that the age of the patient and the pediatric experience of the anesthesiologist, but not the duration of the surgery, are relevant risk factors.  A number of small studies from outside the United States have reported results on cochlear implantation in infants under the age of 12 months, which would be an off-label indication.  For example, in a study from Australia, Ching and colleagues published an interim report on early language outcomes of children with cochlear implants.  This study evaluated 16 children who had implants before twelve months of age compared to 23 who had implants after twelve months (specific time of implantation was not provided).  The preliminary results demonstrated that children who received an implant before twelve months of age developed normal language skills at a rate comparable to normal-hearing children, while those with later implants performed at two standard deviations below normal.  The authors noted that these results are preliminary as there is a need to examine the effect of multiple factors on language outcomes and the rate of language development.  Similarly, in a study from Italy, Colletti reported on findings from 13 infants who had implants placed before twelve months.  The procedures were performed between 1998 and 2004.  In this small study, the rate of receptive language growth for these early-implant infants overlapped scores of normal-hearing children.  This overlap was not detected for those implanted at 12-23 or 24-36 months. 

Guidelines and Position Statements

In 2006, the American Academy of Otolaryngology-Head and Neck Surgery Foundation released criteria for cochlear implants for adults and pediatric patients.

“Adults Criteria

  • 18 years or older, with bilateral, severe to profound sensorineural hearing loss, i.e., 70dB or greater PTA (pure-tone air-conduction average) at 500, 1000, and 2000 Hz;
  • Have tried but have limited benefit from adequately fitted binaural hearing aid; or
  • Have sentence recognition score of 50 percent or less in the ear to be implanted and 60 percent or less in the contralateral ear in best aided conditions using Hearing in Noise Test (HINT) or City University of New York (CUNY) tests.

Pediatric Criteria

  • 12 months to 17 years of age.
  • Infants age 12-24 months should have bilateral, profound hearing loss with thresholds of 90dB or greater at 100 Hz.
  • Children 24 months to 17 years should have bilateral severe to profound (greater than 70dB) hearing loss.
  • Infants and older children should demonstrate lack of progress in simple auditory skills in conjunction with appropriate auditory amplification and participation in intensive aural habilitation for three to six months.  Less than 0.14520 percent correct on the Multi-syllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT), depending on the child’s cognitive and linguistic abilities.
  • A three-to six-month trial of appropriate hearing aids is required. If meningitis is the cause of hearing loss or if there is radiologic evidence of cochlear ossification a shorter hearing aid trial and earlier implantation may be reasonable.”

In May 2008, The British Cochlear Implant Group (BCIG) released a position paper on Bilateral Cochlear Implants.  The position paper includes indications for use of bilateral implantation as noted above.  In January 2009, the National Institute for Health and Clinical Excellence (NICE) released technology appraisal guidance 166, Cochlear Implants for children and adults with severe to profound deafness, which includes recommendations for use of unilateral and bilateral cochlear implants in children and adults as noted above.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

20.96, 20.97, 20.98, 389.10-389.13

ICD-10 Codes
H90.3 – H90.8, 09HD0SY, 09HE0SY, 09HD0S2, 09HE0S2, 09HD0S3, 09HE0S3 
Procedural Codes: 69930, 92601, 92602, 92603, 92604, 92633, L8614, L8615, L8616, L8617, L8618, L8619, L8621, L8622, L8623, L8624, L8627, L8628, L8629
References
  1. 1995 NIH Consensus Conference: Cochlear Implants in Adults and Children: www.opd.od.nih.gov .
  2. Lawson, D.T., Wilson, B.S.,  et al.  Bilateral cochlear implants controlled by a single speech processor.  American Journal of Otolaryngology 1998; 19(6):758-61.
  3. Truy, E., Ionescu, E., et al.  The binaural digisonic cochlear implant: surgical technique.  Otology and Neurotology (2000) 23(5):704-9.
  4. Mawman, D.J., Ramsden, R.T., et al.  Bilateral cochlear implantation - a case report.  Advances in Otolaryngology (2000) 57:360-3.
  5. Muller, J., F. Schon.  Speech understanding in quiet and noise in bilateral users of the MED-EL COMBI 40/40+ cochlear implant system.  Ear Hear (2002) 23(3):198-206.
  6. Van Hoesel, R., Ramsden R.  Sound-direction identification, interaural time delay discrimination, and speech intelligibility advantages in noise for a bilateral cochlear implant user.  Ear Hear (2002) 23(2):137-49.
  7. Schon, F., J. Muller.  Speech reception thresholds obtained in a symmetrical four-loudspeaker arrangement from bilateral users of MED-EL cochlear implants.  Otology and Neurotology (2002) 23(5):710-4.
  8. Gantz, B.J., Tyler, R.S., et al.  Binaural cochlear implants placed during the same operation.  Otology and Neurology (2002) 23(2):169-80.
  9. Tyler, R.S., Gantz, B.J., et al.  Three months results with bilateral cochlear implants. Ear Hear (2002) 23(1 supplement):80S-9S.
  10. Ross, Mark, PhD.  Binaural Hearing with Cochlear Implants.  Hearing Loss (2003May/June)
  11. Thai-Van, H., Gallego, S., et al.  Electrophysiological findings in two bilateral cochlear implant cases: does the duration of deafness affect electrical evoked auditory brain stem responses? Annals of Otolology, Rhinology and Laryngology  (2002) 111(11):1008-14.
  12. Tyler, R.S., Dunn, C.C., et al.  Update on bilateral cochlear implantation.  Current Opinion in Otolaryngology & Head and Neck Surgery (2003 October) 11(5):388-93.
  13. Long, C.J., Eddington, D.K., et al.  Binaural sensitivity as a function of interaural electrode position with a bilateral cochlear implant user.  Journal of the Acoustical Society of America (2003) 114(3):1565-74.
  14. Van Hoesel, R.J., R.S. Tyler.  Speech perception, localization, and lateralization with bilateral cochlear implants.  Journal of the Acoustical Society of America. (2003)113(3):1617-30.
  15. Au, D.K., Y. Hui.  Superiority of bilateral cochlear implantation over unilateral cochlear implantation in tone discrimination in Chinese patients.  American Journal of Otolaryngology (2003) 24(1):19-23.
  16. Vermeire, K., Brokx, J.P., et al.  Bilateral cochlear implantation in children.  International Journal of  Pediatric Otolaryngology (2003) 24(1):67-70.
  17. Laszig, R., Aschendorff, A., et al.  Benefits of bilateral electrical stimulation with the Nucleus cochlear implant in adults: 6 month postoperative results.  Otology and Neurotology (2004 November) 25(6):958-68.
  18. Litovsky, R.Y., Parkinson, A., et al.  Bilateral cochlear implants in adults and children.  Archives of Otolaryngology - Head Neck Surgery (2004 May) 130(5): 648-55.
  19. Kuhn-Inacker, H., Shehata-Dieler, W., et al.  Bilateral cochlear implants: a way to optimize auditory perception abilities in children?  International Journal of Pediatric Otorhinolaryngology (2004 October) 68(10):1257-6.
  20. Ching TY, Incerti P, Hill M.  Binaural benefits for adults who use hearing aids and cochlear implants in opposite ears.  Ear Hear 2004; 25(1):9-21.
  21. Kuhn-Inacker H, Shehata-Dieler W, Muller J et al.  Bilateral cochlear implants: a way to optimize auditory perception abilities in deaf children?  Int J Pediatr Otorhinolaryngol 2004; 68(10):1257-66.
  22. Versachuur, C.A., Lutman, M.E., et al.  Auditory localization abilities in bilateral cochlear implant recipients.  Otology and Neuorotology (2005) 25(5):965-71.
  23. Morera, C., Manrique, M., et al.  Advantages of binaural hearing provided through bimodal stimulation via a cochlear implant and a conventional hearing aid:  a 6 month comparative study. Acta Oto-Laryngologica (2005) 125(6):596-606.
  24. International Consensus on Bilateral Cochlear Implants and Bimodal Simulation.  Second Meeting Consensus on Auditory Implants.  Acta Oto-Laryngologica (2005) 125:918-19.
  25. Schoen, F., Mueller, J., et al.  Sound localization and sensitivity to interaural cues in bilateral users of the Med-El Combi 40/40+ Cochlear Implant System. Otology and Neurotology (2005). 26(3):429-37.
  26. Holt RF, Kirk KI, Eisenberg LS et al. Spoken word recognition development in children with residual hearing using cochlear implants and hearing aids in opposite ears. Ear Hear 2005; 26(4 suppl):82S-91S.
  27. Sharma A, Dorman MF, Kral A. The influence of a sensitive period on central auditory development in children with unilateral and bilateral cochlear implants. Hear Res 2005; 203(1-2):134-43.
  28. Ramsden R, Greenham P, O’Driscoll M et al. Evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system. Otol Neurotol 2005; 26(5):988-98.
  29. Peters, B. Robert, M.D., President of Dallas Hearing Foundation.  Rationale for the Bilateral Cochlear Implantation in Children and Adults.  Part I in a 5 Part Series on binaural hearing and bilateral cochlear implants (2006 May).
  30. Sharma A, Dorman MF. Central auditory development in children with cochlear implants: clinical implications. Adv Otorhinolaryngol 2006; 64:66-88.
  31. Ching TY, Incerti P, Hill M et al.  An overview of binaural advantages for children and adults who use binaural/bimodal hearing devices.  Audiol Neurootol 2006; 11(suppl 1):6-11.
  32. Litovsky RY, Johnstone PM, Godar S et al.  Bilateral cochlear implants in children: localization acuity measures with minimum audible angle.  Ear Hear 2006; 27(1):43-59.
  33. Litovsky R, Parkinson A, Arcaroli J et al.  Simultaneous bilateral cochlear implantation in adults: a multicenter clinical study. Ear Hear 2006; 27(6):714-31.
  34. Ricketts TA, Grantham DW, Ashmead DH et al.  Speech recognition for unilateral and bilateral cochlear implant modes in the presence of uncorrelated noise sources.  Ear Hear 2006; 27(6):763-73.
  35. Blakely BW. Hearing: when surgery is appropriate for age-related hearing loss. In Geriatric Care Otolaryngology. American Academy of Otolaryngology-Head and Neck Surgery Foundation, 2006. Pages 11- 14. Available at: http://www.entnet.org/EducationAndResearch .
  36. Scherf F, van Deun L, van Wieringen A et al.  Hearing benefits of second-side cochlear implantation in two groups of children.  Int J Pediatr Otorhinolaryngol 2007; 71(12):1855-63.
  37. Grantham DW, Ashmead DH, Ricketts TA et al.  Horizontal-plane localization of noise and speech signals by postlingually deafened adults fitted with bilateral cochlear implants. Ear Hear 2007; 28(4):524-41.
  38. Galvin KL, Mok M, Dowell RC.  Perceptual benefit and functional outcomes for children using sequential bilateral cochlear implants. Ear Hear 2007; 28(4):470-82.
  39. Buss E, Pillsbury HC, Buchman CA et al. Multicenter U.S. bilateral MED-EL cochlear implantation study: speech perception over the first year of use. Ear Hear 2008; 29(1):20-32.
  40. Luntz M, Yehudai N, Shpak T. Hearing progress and fluctuations in bimodal-binaural hearing users (unilateral cochlear implants and contralateral hearing aid). Acta Otolaryngology 2007; 127(10):1045-50.
  41. National Institute for Health and Clinical Excellence (NICE). Technology Appraisal Guidance 166. Cochlear implants for children and adults with severe to profound deafness.  Available at: www.nice.org .
  42. Firszt JB, Reeder RM, Skinner MW. Restoring hearing symmetry with two cochlear implants or one cochlear implant and a contralateral hearing aid. J Rehabil Res Dev 2008; 45(5):749-67.
  43. Olson AD, Shinn JB. A systematic review to determine the effectiveness of using amplification in conjunction with cochlear implantation. J Am Acad Audiol 2008; 19(9):657-71.
  44. 37. British Cochlear Implant Group (BCIG). Position Statement - Bilateral Cochlear Implantation. May 2007.  Revised May 2008; Accessed September 2009. Available at: http://www.bcig.org.uk.pdf .
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  46. Bond M, Mealing S, Anderson R et al. The effectiveness and cost-effectiveness of cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health Technol Assess 2009; 13(44):1-330.
  47. Ching TY, Dillon H, Day J et al. Early language outcomes of children with cochlear implants: Interim findings of the NAL study on longitudinal outcomes of children with hearing impairment. Cochlear Implants Int 2009; 10(suppl 1):28-32.
  48. Colletti L. Long-term follow-up of infants (4-11 months) fitted with cochlear implants. Acta Otolaryngol 2009; 129(4):361-6.
  49. Cochlear Implant. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2010 May) Surgery 7.01.05.
History
December 2010  Clarified language regarding not medically necessary upgrade; updated rationale, references. 
August 2012  Policy updated with literature review; Rationale section and references reorganized. No changes in policy statements. Reference numbers 7-9, 13 and 22-24 added. 
September 2013 Added additional criteria to apply to the Medically Necessary statement.  Removed CPT codes 92507, 92605, 92606, 92607, 92608, 92609.  Added CPT code 92633.
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Cochlear Implant