Aetna Cochlear Implants coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Unilateral or bilateral cochlear implant for ADULTS (age 18+) — medically necessary when ALL of the following are met: (1) bilateral pre- or post-linguistic sensorineural moderate-to-profound hearing loss; (2) pure-tone average (PTA) >= 60 dB HL at 500/1000/2000 Hz; (3) limited benefit from appropriately fit hearing aids, defined as monosyllabic word recognition <= 50% on CNC test OR sentence recognition <= 60% correct in the best-aided condition (e.g., AzBio, HINT); (4) cognitive ability to use auditory clues and willingness to undergo post-implant rehabilitation; (5) completed a minimum 30-day hearing aid trial with full-time use (8 hrs/day); (6) assessment by an experienced audiologist and otolaryngologist indicating likelihood of success; (7) no medical contraindications; (8) realistic expectations, good motivation, willingness for extensive post-operative rehabilitation; (9) enrolled in an educational program supporting listening/speaking; (10) arrangements for follow-up care including long-term speech therapy; (11) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).
• Unilateral or bilateral cochlear implant for CHILDREN/INFANTS — medically necessary when ALL of the following are met: (1) bilateral severe-to-profound sensorineural hearing loss with air-conduction PTA >= 70 dB HL at 500/1000/2000 Hz; (2) limited hearing aid benefit, defined as lack of auditory skill development, < 50% accuracy on aided word recognition, OR poor age-appropriate speech recognition despite appropriate amplification (measured by AzBio, BKB-SIN, CNC, ESP, HINT-C, IT-MAIS, MAIS, MLNT/LNT, Pediatric Minimum Speech Test Battery, or Phonetically Balanced Kindergarten Test); (3) completed a 3-6 month hearing aid trial — WAIVED if radiological evidence of cochlear ossification exists; (4) able to participate in a post-implant aural rehabilitation program (a parent/guardian may act as surrogate for a young child); (5) assessment by an experienced audiologist and otolaryngologist indicating likelihood of success; (6) no medical contraindications; (7) realistic expectations and good motivation; (8) enrolled in an educational program supporting listening/speaking; (9) arrangements for follow-up care including long-term speech therapy; (10) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).
• Unilateral cochlear implant for SINGLE-SIDED DEAFNESS (SSD) or ASYMMETRIC HEARING LOSS (AHL), age 1+ — medically necessary when ONE of the following profiles is met: (Option A, SSD) severe-to-profound sensorineural loss in one ear with normal or mild loss in the other ear AND limited benefit from a >= 1-month unilateral hearing aid trial in the implant ear; OR (Option B, AHL) severe-to-profound loss in one ear with mild-to-moderately-severe loss in the other ear AND limited benefit from a >= 1-month unilateral hearing aid trial.
• SSD/AHL definitions used for the eligibility profiles: severe-to-profound = PTA >= 80 dB HL at 500/1000/2000/4000 Hz; normal = PTA <= 15 dB HL; mild = PTA <= 30 dB HL; mild-to-moderately-severe = PTA 31-55 dB HL at those frequencies.
• SSD/AHL limited-benefit definition (one applies by age): for ADULTS 18+, aided speech perception <= 5% on CNC monosyllabic words in quiet; for CHILDREN/ADOLESCENTS, aided speech perception <= 5% on age-appropriate monosyllabic word lists. Additionally requires >= 1 month experience with a hearing aid, CROS hearing aid, or other relevant device with no subjective benefit demonstrated.
• SSD/AHL cochlear implant additionally requires ALL of: assessment by an experienced audiologist and otolaryngologist; no medical contraindications; realistic expectations, good motivation, willingness for rehabilitation; enrolled in an educational program supporting listening/speaking; arrangements for follow-up care including long-term speech therapy; current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).
• HYBRID cochlear implant for ADULTS (age 18+) — medically necessary when ALL of the following are met: (1) severe-to-profound high-frequency sensorineural loss in both ears with residual low-frequency hearing (with or without a hearing aid); (2) normal-to-moderate low-frequency loss (thresholds <= 60 dB HL up to 500 Hz); (3) severe-to-profound mid-to-high frequency loss (threshold average of 2000/3000/4000 Hz >= 75 dB HL) in the implant ear; (4) moderately-severe-to-profound mid-to-high frequency loss (threshold average of 2000/3000/4000 Hz >= 60 dB HL) in the contralateral ear; (5) CNC speech-perception score of 0-60% inclusive in the implant ear (best-aided condition); (6) CNC score in the contralateral ear greater-than-or-equal-to the implant-ear score but <= 80% (best-aided); (7) completed a minimum 30-day hearing aid trial with full-time use (8 hrs/day); (8) patent cochlea with normal anatomy and no ossification or cochlear anomaly preventing electrode array insertion; (9) assessment by an experienced audiologist and otolaryngologist; (10) no medical contraindications; (11) realistic expectations, good motivation, willingness for rehabilitation; (12) enrolled in an educational program supporting listening/speaking; (13) arrangements for follow-up care including long-term speech therapy; (14) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).
• AUDITORY BRAINSTEM IMPLANT (ABI) for members age 12+ — medically necessary for bilateral auditory nerve loss due to ONE of: (a) disease (e.g., neurofibromatosis type 2); OR (b) planned bilateral surgical removal of auditory nerve tumors expected to result in complete bilateral deafness.
• Sequential BILATERAL cochlear implantation — a person with an existing unilateral cochlear implant may qualify for subsequent (second-side) implantation WITHOUT retesting if the medical records document that the prior medical-necessity criteria were satisfied.
• REPLACEMENT of cochlear implant internal/device components — medically necessary when ONE of: (a) the existing device is non-functional and cannot be repaired; OR (b) replacement is required because a change in the member's condition renders the unit non-functional AND improvement is expected with replacement.
• UPGRADE or REPLACEMENT of external speech processor/controller — medically necessary when ONE of: (a) the member's response to existing components is inadequate and interferes with activities of daily living; OR (b) components are non-functional and cannot be repaired. NOT covered for convenience or aesthetics if components remain functional.
• Accessories and upgrades to a cochlear implant — covered only after a separate assessment based on the member's current condition, current capabilities, and the upgrade/accessory capabilities, AND only when they offer clinically significant benefit.
• AURAL REHABILITATION following cochlear implantation — medically necessary to achieve implant benefit (typically 6-10 sessions of approximately 2.5 hours each); see CPB 0034.
• VESTIBULAR EVOKED MYOGENIC POTENTIAL (VEMP) testing — medically necessary for predicting post-operative complications from cochlear implantation.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 69930·PA verdict·Rate
• 92601·PA verdict·Rate
• 92602·PA verdict·Rate
• 92603·PA verdict·Rate
• 92604·PA verdict·Rate
• 92630·PA verdict·Rate
• 92633·PA verdict·Rate
• L8614·PA verdict·Rate
• S2235·PA verdict·Rate

Documentation required

• Audiological and otolaryngologic assessment reports confirming candidacy
• Hearing loss severity documented by pure-tone audiometry at the specified frequencies
• Speech perception test results with specific test scores documented
• Hearing aid trial documentation (dates, device models, hours per day, and duration)
• Medical contraindication screening report
• Radiological evidence (MRI/CT) confirming cochlear anatomy and ruling out ossification or aplasia
• Pneumococcal vaccination status and dates
• Educational enrollment confirmation (program supporting listening/speaking)
• Follow-up care arrangement documentation (speech therapy plan)

Frequently asked questions

When does Aetna cover Cochlear Implants (CPT 69930), and what gets it denied?

Aetna covers cochlear implants (unilateral, bilateral, hybrid, or for single-sided/asymmetric hearing loss) and auditory brainstem implants as medically necessary only when strict, age-specific criteria are met — including documented bilateral sensorineural hearing loss at specified thresholds, defined limited benefit from a completed hearing aid trial, audiologist/otolaryngologist assessment, absence of contraindications, and commitment to post-implant aural rehabilitation. Component replacement/upgrade and aural rehabilitation are covered when devices fail or response is inadequate, while uses such as tinnitus, auditory neuropathy/dyssynchrony, and various adjunct tests are considered experimental or not covered. Coverage criteria include: Unilateral or bilateral cochlear implant for ADULTS (age 18+) — medically necessary when ALL of the following are met: (1) bilateral pre- or post-linguistic sensorineural moderate-to-profound hearing loss; (2) pure-tone average (PTA) >= 60 dB HL at 500/1000/2000 Hz; (3) limited benefit from appropriately fit hearing aids, defined as monosyllabic word recognition <= 50% on CNC test OR sentence recognition <= 60% correct in the best-aided condition (e.g., AzBio, HINT); (4) cognitive ability to use auditory clues and willingness to undergo post-implant rehabilitation; (5) completed a minimum 30-day hearing aid trial with full-time use (8 hrs/day); (6) assessment by an experienced audiologist and otolaryngologist indicating likelihood of success; (7) no medical contraindications; (8) realistic expectations, good motivation, willingness for extensive post-operative rehabilitation; (9) enrolled in an educational program supporting listening/speaking; (10) arrangements for follow-up care including long-term speech therapy; (11) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).; Unilateral or bilateral cochlear implant for CHILDREN/INFANTS — medically necessary when ALL of the following are met: (1) bilateral severe-to-profound sensorineural hearing loss with air-conduction PTA >= 70 dB HL at 500/1000/2000 Hz; (2) limited hearing aid benefit, defined as lack of auditory skill development, < 50% accuracy on aided word recognition, OR poor age-appropriate speech recognition despite appropriate amplification (measured by AzBio, BKB-SIN, CNC, ESP, HINT-C, IT-MAIS, MAIS, MLNT/LNT, Pediatric Minimum Speech Test Battery, or Phonetically Balanced Kindergarten Test); (3) completed a 3-6 month hearing aid trial — WAIVED if radiological evidence of cochlear ossification exists; (4) able to participate in a post-implant aural rehabilitation program (a parent/guardian may act as surrogate for a young child); (5) assessment by an experienced audiologist and otolaryngologist indicating likelihood of success; (6) no medical contraindications; (7) realistic expectations and good motivation; (8) enrolled in an educational program supporting listening/speaking; (9) arrangements for follow-up care including long-term speech therapy; (10) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).; Unilateral cochlear implant for SINGLE-SIDED DEAFNESS (SSD) or ASYMMETRIC HEARING LOSS (AHL), age 1+ — medically necessary when ONE of the following profiles is met: (Option A, SSD) severe-to-profound sensorineural loss in one ear with normal or mild loss in the other ear AND limited benefit from a >= 1-month unilateral hearing aid trial in the implant ear; OR (Option B, AHL) severe-to-profound loss in one ear with mild-to-moderately-severe loss in the other ear AND limited benefit from a >= 1-month unilateral hearing aid trial.; SSD/AHL definitions used for the eligibility profiles: severe-to-profound = PTA >= 80 dB HL at 500/1000/2000/4000 Hz; normal = PTA <= 15 dB HL; mild = PTA <= 30 dB HL; mild-to-moderately-severe = PTA 31-55 dB HL at those frequencies.; SSD/AHL limited-benefit definition (one applies by age): for ADULTS 18+, aided speech perception <= 5% on CNC monosyllabic words in quiet; for CHILDREN/ADOLESCENTS, aided speech perception <= 5% on age-appropriate monosyllabic word lists. Additionally requires >= 1 month experience with a hearing aid, CROS hearing aid, or other relevant device with no subjective benefit demonstrated.; SSD/AHL cochlear implant additionally requires ALL of: assessment by an experienced audiologist and otolaryngologist; no medical contraindications; realistic expectations, good motivation, willingness for rehabilitation; enrolled in an educational program supporting listening/speaking; arrangements for follow-up care including long-term speech therapy; current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).; HYBRID cochlear implant for ADULTS (age 18+) — medically necessary when ALL of the following are met: (1) severe-to-profound high-frequency sensorineural loss in both ears with residual low-frequency hearing (with or without a hearing aid); (2) normal-to-moderate low-frequency loss (thresholds <= 60 dB HL up to 500 Hz); (3) severe-to-profound mid-to-high frequency loss (threshold average of 2000/3000/4000 Hz >= 75 dB HL) in the implant ear; (4) moderately-severe-to-profound mid-to-high frequency loss (threshold average of 2000/3000/4000 Hz >= 60 dB HL) in the contralateral ear; (5) CNC speech-perception score of 0-60% inclusive in the implant ear (best-aided condition); (6) CNC score in the contralateral ear greater-than-or-equal-to the implant-ear score but <= 80% (best-aided); (7) completed a minimum 30-day hearing aid trial with full-time use (8 hrs/day); (8) patent cochlea with normal anatomy and no ossification or cochlear anomaly preventing electrode array insertion; (9) assessment by an experienced audiologist and otolaryngologist; (10) no medical contraindications; (11) realistic expectations, good motivation, willingness for rehabilitation; (12) enrolled in an educational program supporting listening/speaking; (13) arrangements for follow-up care including long-term speech therapy; (14) current pneumococcal vaccination (>= 2 weeks pre-surgery when possible).; AUDITORY BRAINSTEM IMPLANT (ABI) for members age 12+ — medically necessary for bilateral auditory nerve loss due to ONE of: (a) disease (e.g., neurofibromatosis type 2); OR (b) planned bilateral surgical removal of auditory nerve tumors expected to result in complete bilateral deafness.; Sequential BILATERAL cochlear implantation — a person with an existing unilateral cochlear implant may qualify for subsequent (second-side) implantation WITHOUT retesting if the medical records document that the prior medical-necessity criteria were satisfied.; REPLACEMENT of cochlear implant internal/device components — medically necessary when ONE of: (a) the existing device is non-functional and cannot be repaired; OR (b) replacement is required because a change in the member's condition renders the unit non-functional AND improvement is expected with replacement.; UPGRADE or REPLACEMENT of external speech processor/controller — medically necessary when ONE of: (a) the member's response to existing components is inadequate and interferes with activities of daily living; OR (b) components are non-functional and cannot be repaired. NOT covered for convenience or aesthetics if components remain functional.; Accessories and upgrades to a cochlear implant — covered only after a separate assessment based on the member's current condition, current capabilities, and the upgrade/accessory capabilities, AND only when they offer clinically significant benefit.; AURAL REHABILITATION following cochlear implantation — medically necessary to achieve implant benefit (typically 6-10 sessions of approximately 2.5 hours each); see CPB 0034.; VESTIBULAR EVOKED MYOGENIC POTENTIAL (VEMP) testing — medically necessary for predicting post-operative complications from cochlear implantation.. Applies to 9 codes: 69930, 92601, 92602, 92603, 92604, 92630, 92633, L8614, S2235. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Audiological and otolaryngologic assessment reports confirming candidacy; Hearing loss severity documented by pure-tone audiometry at the specified frequencies; Speech perception test results with specific test scores documented; Hearing aid trial documentation (dates, device models, hours per day, and duration); Medical contraindication screening report; Radiological evidence (MRI/CT) confirming cochlear anatomy and ruling out ossification or aplasia; Pneumococcal vaccination status and dates; Educational enrollment confirmation (program supporting listening/speaking); Follow-up care arrangement documentation (speech therapy plan). Policy exclusions and limitations: Auditory brainstem implant for cochlear ossification (otosclerosis), congenital deafness, or tinnitus — experimental/investigational/unproven.; Auditory brainstem implant combined with a contralateral cochlear implant for children with cochlear nerve deficiency — experimental/investigational/unproven.; Cochlear implantation for auditory dyssynchrony, auditory neuropathy spectrum disorder, or post-synaptic auditory neuropathy — experimental/investigational/unproven.; Cochlear implantation for tinnitus — experimental/investigational/unproven.; Cochlear implantation for any other indication not listed as covered in this bulletin — experimental/investigational/unproven.; Cochlear implantation in persons with osteogenesis imperfecta who do NOT meet the medical-necessity criteria — experimental/investigational/unproven.; Cortical auditory evoked potentials for evaluating cochlear implant candidacy — experimental/investigational/unproven.; Electrocochleography for monitoring hearing preservation in cochlear implant users with preserved hearing — experimental/investigational/unproven.; Intraoperative electrically-evoked auditory brainstem response measurements for predicting hearing outcomes after vestibular schwannoma resection and implantation — experimental/investigational/unproven.; Musical/rhythmic training for linguistic skill development in children/adolescents with cochlear implants — experimental/investigational/unproven.; Pre-operative cochlear nerve diameter measurement for predicting speech perception in cochlear implant recipients — experimental/investigational/unproven.; Cochlear implants for conductive hearing loss alone — not medically necessary/not covered (unless bilateral sensorineural thresholds meet the coverage criteria).; Cochlear implants for unspecified hearing loss without a documented bilateral sensorineural component — not medically necessary/not covered.; Cochlear implants for central auditory processing disorder — not covered (also listed among non-covered/experimental neuropathy-type indications).; Replacement or upgrade of external speech processor/controller for convenience or aesthetics when existing components remain functional — not covered.; Any indication not explicitly listed as a covered indication in this bulletin — not covered.; Contraindication (basis for non-coverage): dysfunctional acoustic nerve.; Contraindication (basis for non-coverage): cochlear aplasia (lack of cochlear development).; Contraindication (basis for non-coverage): active middle ear infection.; Contraindication (basis for non-coverage): medical contraindications to surgery / uncontrolled medical conditions precluding safe surgery.; Contraindication (basis for non-coverage): absence of cognitive ability to use auditory clues.; Contraindication (basis for non-coverage): unwillingness to participate in post-operative rehabilitation. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Cochlear Implants?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Audiological and otolaryngologic assessment reports confirming candidacy; Hearing loss severity documented by pure-tone audiometry at the specified frequencies; Speech perception test results with specific test scores documented; Hearing aid trial documentation (dates, device models, hours per day, and duration); Medical contraindication screening report; Radiological evidence (MRI/CT) confirming cochlear anatomy and ruling out ossification or aplasia; Pneumococcal vaccination status and dates; Educational enrollment confirmation (program supporting listening/speaking); Follow-up care arrangement documentation (speech therapy plan).

What does Aetna exclude for Cochlear Implants?

Policy exclusions and limitations: Auditory brainstem implant for cochlear ossification (otosclerosis), congenital deafness, or tinnitus — experimental/investigational/unproven.; Auditory brainstem implant combined with a contralateral cochlear implant for children with cochlear nerve deficiency — experimental/investigational/unproven.; Cochlear implantation for auditory dyssynchrony, auditory neuropathy spectrum disorder, or post-synaptic auditory neuropathy — experimental/investigational/unproven.; Cochlear implantation for tinnitus — experimental/investigational/unproven.; Cochlear implantation for any other indication not listed as covered in this bulletin — experimental/investigational/unproven.; Cochlear implantation in persons with osteogenesis imperfecta who do NOT meet the medical-necessity criteria — experimental/investigational/unproven.; Cortical auditory evoked potentials for evaluating cochlear implant candidacy — experimental/investigational/unproven.; Electrocochleography for monitoring hearing preservation in cochlear implant users with preserved hearing — experimental/investigational/unproven.; Intraoperative electrically-evoked auditory brainstem response measurements for predicting hearing outcomes after vestibular schwannoma resection and implantation — experimental/investigational/unproven.; Musical/rhythmic training for linguistic skill development in children/adolescents with cochlear implants — experimental/investigational/unproven.; Pre-operative cochlear nerve diameter measurement for predicting speech perception in cochlear implant recipients — experimental/investigational/unproven.; Cochlear implants for conductive hearing loss alone — not medically necessary/not covered (unless bilateral sensorineural thresholds meet the coverage criteria).; Cochlear implants for unspecified hearing loss without a documented bilateral sensorineural component — not medically necessary/not covered.; Cochlear implants for central auditory processing disorder — not covered (also listed among non-covered/experimental neuropathy-type indications).; Replacement or upgrade of external speech processor/controller for convenience or aesthetics when existing components remain functional — not covered.; Any indication not explicitly listed as a covered indication in this bulletin — not covered.; Contraindication (basis for non-coverage): dysfunctional acoustic nerve.; Contraindication (basis for non-coverage): cochlear aplasia (lack of cochlear development).; Contraindication (basis for non-coverage): active middle ear infection.; Contraindication (basis for non-coverage): medical contraindications to surgery / uncontrolled medical conditions precluding safe surgery.; Contraindication (basis for non-coverage): absence of cognitive ability to use auditory clues.; Contraindication (basis for non-coverage): unwillingness to participate in post-operative rehabilitation. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT