Persons with single-sided deafness (SSD) who have severe to profound sensorineural hearing loss in one ear and normal hearing or mild sensorineural hearing loss in the other ear, who have obtained limited benefit from a one-month or longer trial of an appropriately fitted unilateral hearing aid in the ear to be implanted or.Note: When there is radiological evidence of cochlear ossification, this requiremet may be waived at Aetna’s discretion.Īetna considers uniaural (monaural) cochlear implantation medically necessary for individuals aged 1 year and older with single sided deafness (SSD) or asymmetric hearing loss (AHL) who meet the following criteria: A 3- to 6-month hearing aid trial has been undertaken by a child without previous experience with hearing aids.For children older than 4 years of age, limited benefit is defined as less than 12 % correct on the Phonetically Balanced-Kindergarten Test, or less than 30 % correct on the Hearing in Noise Test for children, the open-set Multi-syllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT), depending on the child's cognitive ability and linguistic skills and For children 4 years of age or younger, limited benefit is defined as failure to reach developmentally appropriate auditory milestones measured using the Infant-Toddler Meaningful Auditory Integration Scale, the Meaningful Auditory Integration Scale, or the Early Speech Perception test, or less than 20 % correct on open-set word recognition test (Multisyllabic Lexical Neighborhood Test) in conjunction with appropriate amplification and participation in intensive aural habilitation over a 3 to 6 month period. Child has limited benefit from appropriately fitted binaural hearing aids.Child has profound, bilateral sensorineural hearing loss determined by an air conduction pure tone average of 70 dB or greater at 500 Hz, and 90 dB or greater at 10 Hz and.Note: Adults with bilateral hearing loss needing cochlear implants must have completed a hearing aid trial of at least 30 days with aids worn full time (8 hours per day).Īetna considers uniaural (monaural) or binaural (bilateral) cochlear implantation a medically necessary prosthetic for infants and children with bilateral sensorineural hearing impairment who meet all of the following criteria: Limited benefit from amplification is defined by test scores of 40 % correct or less in best-aided listening condition on open-set sentence cognition (e.g., Central Institute for the Deaf (CID) sentences, Hearing in Noise Test sentences (HINT), and consonant-nucleus-consonant (CNC) test. Member has limited benefit from appropriately fitted binaural hearing aids.
Member has bilateral severe to profound sensorineural hearing loss determined by an air conduction pure tone average of 70 dB or greater at 500 Hz, 1000 Hz, and 2000 Hz and.This Clinical Policy Bulletin addresses cochlear implants and auditory brainstem implants.Īetna considers an auditory brainstem implant (ABI) medically necessary in members 12 years of age or older who have lost both auditory nerves due to disease (e.g., neurofibromatosis or von Recklinghausen's disease) or bilateral surgical removal of auditory nerve tumors is planned and is expected to result in complete bilateral deafness.Īetna considers uniaural (monaural) or binaural (bilateral) cochlear implantation a medically necessary prosthetic for adults aged 18 years and older with bilateral, pre- or post-linguistic, sensorineural, moderate-to-profound hearing impairment who meet both of the following criteria: Number: 0013 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References