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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

 Uniaural (monaural) or binaural (bilateral) cochlear implantation

Uniaural (monaural) or binaural (bilateral) cochlear implantation

Uniaural (monaural) or binaural (bilateral) cochlear implantation and necessary replacement batteries are covered for a member with bilateral, pre- or post-linguistic, sensorineural, moderate to profound hearing impairment when there is reasonable expectation that a significant benefit will be achieved from the device and when the following age-specific criteria are met:

  • For an adult (age 18 years or older) with BOTH of the following:
    • Bilateral, severe to profound sensorineural hearing loss determined by a pure-tone average of 70 db (decibels) hearing loss or greater at 500 Hz (hertz), 1000 Hz and 2000 Hz;
    • Member has limited benefit from appropriately fitted binaural hearing aids. 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).
  • For a child (age 12 months to 17 years, 11 months) with both of the following:
    • Profound, bilateral sensorineural hearing loss with thresholds of 90 dB or greater at 1000 Hz; and
    • Limited or no benefit from a three-month trial of appropriately fitted binaural hearing aids.
      • 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 three- to six-month period;
      • 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
      • A three- to six-month hearing aid trial has been undertaken by a child without previous experience with hearing aids. Note: When there is radiological evidence of cochlear ossification, this requirement may be waived at MCHCP's discretion.
  • The following additional medical necessity criteria must also be met for uniaural (monaural) or binaural (bilateral) cochlear implantation in adults and children:
    • The member must be enrolled in an educational program that supports listening and speaking with aided hearing; and
    • The member must have had an assessment by an audiologist and from an otolaryngologist experienced in this procedure indicating the likelihood of success with this device; and
    • The member must have no medical contraindications to cochlear implantation (e.g., cochlear aplasia, active middle ear infection); and
    • The member must have arrangements for appropriate follow-up care, including the speech therapy required to take full advantage of this device.

 Second cochlear implant in opposite (contralateral) ear

Second cochlear implant in opposite (contralateral) ear

MCHCP covers a second cochlear implant in the opposite (contralateral) ear as medically necessary in an individual with an existing unilateral cochlear implant when the hearing aid in the contralateral ear produces limited or no benefit.

 Replacement of existing cochlear implant

Replacement of existing cochlear implant

MCHCP covers the replacement of an existing cochlear implant as medically necessary when EITHER of the following criteria is met:

  • Currently used component is no longer functional and cannot be repaired;
  • Currently used component renders the implant recipient unable to adequately and/or safely perform his/her age-appropriate activities of daily living.

 Auditory Brainstem Implant (ABI)

Auditory Brainstem Implant (ABI)

Covered as medically necessary when member is 12 or older and either of the following criteria are met:

  • Diagnosis of neurofibromatosis type 2 or von Recklinghausen's disease;
  • Member is undergoing bilateral removal of tumors of the auditory nerves, and it is anticipated that the individual will become completely deaf as a result of the surgery, or individual had bilateral auditory nerve tumors removed and is now bilaterally deaf.

 Rehabilitation

Rehabilitation

For an adult or child, a post-cochlear or auditory brainstem implant rehabilitation program (aural rehabilitation) is covered to achieve benefit from the device.

 Not Covered by MCHCP Plans

Not Covered by MCHCP Plans

  • Upgrading of a cochlear implant system or component (e.g., upgrading processor from body-worn to behind-the-ear, upgrading from single- to multi-channel electrodes) of an existing, properly functioning cochlear implant because it is considered not medically necessary;
  • A cochlear implant for the treatment of tinnitus in an individual who does not also have profound or severe sensorineural deafness/hearing loss warranting the need for cochlear implantation because such use is considered experimental, investigational or unproven.

Preauthorization by medical plan is required for cochlear implant device or auditory brainstem implant (ABI).


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