Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a cochlear implant device is an electronic instrument, part of which is implanted surgically to 
stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture, analyze, and 
code sound. Cochlear implant devices are available in single-channel and multi-channel models. The purpose 
of implanting the device is to provide awareness and identification of sounds and to facilitate communication 
for persons who are moderately to profoundly hearing impaired. 
 
1. Effective for services performed on or after April 4, 2005, cochlear implantation may be covered 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 less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-
set sentence cognition. Medicare coverage is provided only for those patients who meet all of the following 
selection guidelines. 
 
    Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from 
appropriate hearing (or vibrotactile) aids; 
    Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation; 
    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; 
    No contraindications to surgery; and 
    The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling. 
 
2. Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for 
individuals meeting the selection guidelines above and with hearing test scores of greater than 40% and less 
than or equal to 60% only when the provider is participating in, and patients are enrolled in, either an FDA-
approved category B investigational device exemption clinical trial as defined at 42 CFR 405.201, a trial under 
the Centers for Medicare & Medicaid (CMS) Clinical Trial Policy as defined at section 310.1 of the National 
Coverage Determinations Manual, or a prospective, controlled comparative trial approved by CMS as 
consistent with the evidentiary requirements for National Coverage Analyses and meeting specific quality 
standards. 
 
Medicare beneficiaries not meeting all of the coverage criteria for cochlear implantation listed are deemed not 
eligible for Medicare coverage under section 1862(a)(1)(A) of the Social Security Act. 
 All other indications for cochlear implantation not otherwise indicated as nationally covered or non-covered 
above remain at local Medicare Administrator Contractor discretion. You can find these rules in the National 
Coverage Determination (NCD) Cochlear Implantation 50.3. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.