Current through September 24, 2024
A. Medicaid covers
for unilateral cochlear implantation when there is documentation that
demonstrates the procedure is medically necessary and would be beneficial in
reducing limitations of hearing impairment.
B. The following must be documented by the
surgeon and/or audiologist:
1. Severe to
profound sensorineural hearing loss in both ears as defined by FDA criteria
with a lack of benefit from a well-fitting aid,
2. Cognitive ability to use auditory clues,
patient motivation and a willingness to undergo an extended program of
rehabilitation,
3. 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,
4. No contraindications to surgery,
and
5. The device must be used in
accordance with the FDA approved labeling.
C. Documentation for children twelve (12)
months of age to seventeen (17) years of age must include:
1. The onset of hearing impairment must have
occurred during the pre-or post-linguistic period, and
2. Bilateral severe to profound sensorineural
deafness must be demonstrated by the inability to improve on age-appropriate
closed set word identification tasks with amplification, or lack of progress in
auditory training.
D.
Documentation for adults eighteen (18) years of age and older must include:
1. The onset of hearing impairment must have
occurred during the pre-linguistic, peri-linguistic, or post-linguistic period,
and
2. Post-linguistic deafened
adults must demonstrate current FDA guidelines on test scores on sentence
recognition scores from tape-recorded tests in the beneficiary's best listening
condition.
E. Medicaid
covers bilateral cochlear implantation when there is documentation that
demonstrates the procedure is medically necessary and would be beneficial in
reducing limitations of hearing impairment. Bilateral cochlear implantation
must meet all of the criteria for unilateral cochlear implantation, above, in
addition to the following criteria and circumstances.
F. Medicaid covers bilateral cochlear
implants under two (2) different circumstances:
1. Simultaneous bilateral cochlear implants,
and
2. Subsequent contralateral
cochlear implantation in patients who have already received a previous
unilateral cochlear implant.
G. Simultaneous bilateral cochlear implants
are covered for beneficiaries who:
1. Have
significant deafness, caused by meningitis with subsequent risk for early
cochlear ossification, and, in the opinion of the treating physician, are
appropriate candidates for bilateral cochlear implantation for the syndrome of
post-meningitis deafness prior to cochlear ossification, or
2. Pre-lingually deaf children with profound
hearing loss, and who, in the opinion of the treating specialist physician,
would benefit from the additional neuronal stimulation afforded by simultaneous
bilateral cochlear implantation at an early age. Some patients in this category
may, in the opinion of the treating specialist physician, benefit from a staged
or subsequent contralateral cochlear implantation as opposed to a simultaneous
implantation.
H.
Subsequent contralateral cochlear implantation are covered for beneficiaries
who:
1. Have bilateral profound deafness that
have fallen short of communication goals despite prior placement of a
unilateral cochlear implant, and in the opinion of the treating specialist
physician, would substantially benefit from a subsequent contralateral cochlear
implant,
2. Are prelingually deaf
children with bilateral profound hearing loss who have had prior unilateral
cochlear implantation and who, in the opinion of the treating specialist
physician, would substantially benefit from a subsequent contralateral cochlear
implant, or
3. Have bilateral
auditory neuropathy to the extent such that their cochlear function is
structurally normal but who have abnormal findings on auditory brainstem
response testing, and, in the opinion of the treating specialist physician,
would substantially benefit from a subsequent contralateral cochlear
implant.
I. Medicaid
does not cover for bilateral cochlear implantation, either as a simultaneous
procedure or a subsequent contralateral implantation if, in the opinion of the
treating physician, audiologist, or therapist, the beneficiary has sufficient
limited hearing in the lesser affected ear either could either be:
1. Sufficiently augmented by a hearing aid to
augment the opposite cochlear implant, or
2. Could later benefit from a future surgical
or other medical intervention to improve the hearing in the non-implanted
ear.
J. Medicaid covers
a subsequent contra-lateral cochlear implant procedure, the testing, services
and procedures, to properly evaluate a beneficiary and address the proper
post-operative care and therapy for a second cochlear implant, when the
beneficiary already has a unilateral cochlear implant.
K. Medicaid does not cover the cost of the
cochlear implant device through the Durable Medical Equipment program. The cost
of the device is covered by the usual reimbursement methodology for either
inpatient or outpatient hospital services and must be billed by the hospital.
Medicaid does not cover additional benefits for the device if the surgical
procedure is performed in any other outpatient settings.
L. Medicaid covers the repair and/or
replacement of the cochlear implant external speech processor and other minor
supplies including batteries, cords, battery charger, and headsets through the
Durable Medical Equipment (DME) program. Medicaid covers these items for all
beneficiaries by DME providers only. Medicaid requires prior approval for
repairs or replacements of external implant parts.
M. Medicaid requires documentation by the
provider of rehabilitative services supporting medical necessity and must be
retained in the beneficiary's medical record.
Miss. Code Ann. §
43-13-121
