NC Division of Medical Assistance Medicaid and Health Choice Cochlear and Auditory Clinical Coverage Policy No: 1A-4 Brainstem Implants Amended Date: DRAFT 17J24 Public Comment i Table of Contents 1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Definitions .......................................................................................................................... 1 2.0 Eligibility Requirements .................................................................................................................. 1 2.1 Provisions............................................................................................................................ 1 2.1.1 General ................................................................................................................... 1 2.2 Special Provisions ............................................................................................................... 2 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age ....................................................................... 2 2.2.2 EPSDT does not apply to NCHC beneficiaries ..................................................... 3 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age ....................................................................................................... 3 3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 3 3.1 General Criteria Covered .................................................................................................... 3 3.2 Specific Criteria Covered.................................................................................................... 3 3.2.1 Specific criteria covered by both Medicaid and NCHC ........................................ 3 3.2.2 Cochlear Implant.................................................................................................... 3 3.2.3 Auditory Brainstem Implants................................................................................. 4 3.2.4 Upgrades and Maintenance .................................................................................... 5 3.2.5 Contralateral Cochlear Implant .............................................................................. 5 3.2.6 Simultaneous Bilateral Cochlear Implants............................................................. 6 3.2.7 Diagnostic Analysis and Programming ................................................................. 6 3.2.8 Medicaid Additional Criteria Covered................................................................... 6 3.2.9 NCHC Additional Criteria Covered ...................................................................... 6 4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 7 4.1 General Criteria Not Covered ............................................................................................. 7 4.2 Specific Criteria Not Covered............................................................................................. 7 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC ................................ 7 4.2.2 Medicaid Additional Criteria Not Covered............................................................ 7 4.2.3 NCHC Additional Criteria Not Covered................................................................ 7 5.0 Requirements for and Limitations on Coverage .............................................................................. 8 5.1 Prior Approval .................................................................................................................... 8 5.1.1 Cochlear Implant.................................................................................................... 8 5.1.2 Auditory Brainstem Implant .................................................................................. 8 5.1.3 Upgrades and Maintenance .................................................................................... 8 5.1.4 Contralateral Cochlear Implant .............................................................................. 8 5.1.5 Simultaneous Bilateral Cochlear Implants............................................................. 8 5.1.6 Aural Rehabilitation............................................................................................... 9 5.1.7 Diagnostic Analysis and Programming ................................................................. 9 5.1.8 Replacement Parts and Repairs.............................................................................. 9 5.2 Prior Approval Requirements ............................................................................................. 9 5.2.1 General ................................................................................................................... 9
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NC Division of Medical Assistance Medicaid and Health Choice
Cochlear and Auditory Clinical Coverage Policy No: 1A-4
Brainstem Implants Amended Date:
DRAFT
17J24 Public Comment i
Table of Contents
1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Definitions .......................................................................................................................... 1
2.1.1 General ................................................................................................................... 1 2.2 Special Provisions ............................................................................................................... 2
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid
Beneficiary under 21 Years of Age ....................................................................... 2 2.2.2 EPSDT does not apply to NCHC beneficiaries ..................................................... 3 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through
18 years of age ....................................................................................................... 3
3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 3 3.1 General Criteria Covered .................................................................................................... 3 3.2 Specific Criteria Covered .................................................................................................... 3
4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 7 4.1 General Criteria Not Covered ............................................................................................. 7 4.2 Specific Criteria Not Covered ............................................................................................. 7
4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC ................................ 7 4.2.2 Medicaid Additional Criteria Not Covered ............................................................ 7 4.2.3 NCHC Additional Criteria Not Covered................................................................ 7
5.0 Requirements for and Limitations on Coverage .............................................................................. 8 5.1 Prior Approval .................................................................................................................... 8
5.2 Prior Approval Requirements ............................................................................................. 9 5.2.1 General ................................................................................................................... 9
NC Division of Medical Assistance Medicaid and Health Choice
Cochlear and Auditory Clinical Coverage Policy No: 1A-4
Brainstem Implants Amended Date:
DRAFT
17J24 Public Comment ii
6.0 Providers Eligible to Bill for the Procedure, Product, or Service .................................................... 9 6.1 Provider Qualifications and Occupational Licensing Entity Regulations ........................... 9 6.2 Provider Certifications ........................................................................................................ 9
8.0 Policy Implementation/Revision Information ................................................................................ 10
Attachment A: Claims-Related Information ............................................................................................... 12 A. Claim Type ....................................................................................................................... 12 B. International Classification of Diseases, Tenth Revisions, Clinical Modification (ICD-10-
CM) and Procedural Coding System (PCS) ...................................................................... 12 C. Code(s) .............................................................................................................................. 12 D. Modifiers ........................................................................................................................... 13 E. Billing Units ...................................................................................................................... 13 F. Place of Service ................................................................................................................ 13 G. Co-payments ..................................................................................................................... 13 H. Reimbursement ................................................................................................................. 13
NC Division of Medical Assistance Medicaid and Health Choice
Cochlear and Auditory Clinical Coverage Policy No: 1A-4
Brainstem Implants Amended Date:
DRAFT
CPT codes, descriptors, and other data only are copyright 2016 American Medical Association.
All rights reserved. Applicable FARS/DFARS apply.
17J24 Public Comment 1
Related Clinical Coverage Policies Refer to http://dma.ncdhhs.gov/ for the related coverage policies listed below:
13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair
10A, Outpatient Specialized Therapies
1.0 Description of the Procedure, Product, or Service
A cochlear implant device is an electronic instrument, part of which is implanted surgically into
the cochlea to stimulate auditory nerve fibers and part of which is capable of detecting and
codifying sound for neural stimulation and is worn or carried by the individual. The goal of
implantation is to enable an awareness of sound, identification of sounds, and facilitation of
auditory/oral communication for individuals with severe to profound sensorineural hearing loss.
A cochlear implant is an electronic medical device designed to restore the ability to perceive
sounds and understand speech by individuals with moderate to profound hearing loss. A cochlear
implant bypasses damaged hair cells in the cochlea and stimulates the remaining nerve fibers
directly through the application of electrical current. Cochlear implants have external parts and
internal (surgically implanted) parts that work together to allow the user to perceive sound.
An auditory brainstem implant (ABI) is a modification of the cochlear implant in which the
stimulating electrode is placed directly into the brain.
After surgery, these two devices require activation, fitting of essential external components,
programming, and rehabilitation for proper function and benefit.
1.1 Definitions
None Apply.
2.0 Eligibility Requirements
2.1 Provisions
2.1.1 General
(The term “General” found throughout this policy applies to all Medicaid and
NCHC policies)
a. An eligible beneficiary shall be enrolled in either:
1. the NC Medicaid Program (Medicaid is NC Medicaid program, unless
context clearly indicates otherwise); or
2. the NC Health Choice (NCHC is NC Health Choice program, unless
context clearly indicates otherwise) Program on the date of service and
shall meet the criteria in Section 3.0 of this policy.
b. Provider(s) shall verify each Medicaid or NCHC beneficiary’s eligibility