Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Sensorineural hearing loss (SNHL) involves damage either to the cochlea or to the neural pathways from the retro cochlea to the brain. The most common form of SNHL occurs when the cilia lining the cochlea area are lost and there is no way for sound waves entering the cochlea to be transformed into nerve impulses. If the neural elements that transmit information from the cochlea to the auditory cortex of the brain are intact and functional, it is possible to stimulate the auditory nerve with a prosthetic cochlear implant device designed to perform the function of cochlear hair cells, thereby restoring some degree of hearing.
Conditions of Coverage
- Bilateral Cochlear Implants are covered for patients who are ≥ 12 months or older;
- Bilateral severe to profound sensorineural hearing loss;
- Limited or no benefit from hearing aids;
- Cognitive ability and willingness to participate in an extensive auditory rehabilitation program;
- 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 other contraindications for surgery; and
- Device used in accordance with the FDA approved labeling.
Background Policy Information
The State Health Technology Clinical Committee (HTCC) reviewed cochlear implants: bilateral versus unilateral on May 17, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that bilateral cochlear implants are covered benefits with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.
Implementation of the Determination
Bilateral cochlear implants may be used only for care of a condition accepted on the claim. All requests require prior authorization.