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Processor Upgrades and Parts Replacements for Cochlear Implants
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Processor Upgrades and Parts Replacements for Cochlear Implants:
Pursuing the In-Network Option from Your Insurer

 

By Barbara T. Mellert MPH, Academic Technology Consulting, Dartmouth College, Parent of Two Children with Cochlear Implants

As the mother of two adult sons who are now 25 and 23, I have witnessed how much they have benefitted from their bilateral cochlear implants (CI). The gains they have enjoyed from cochlear implantation are extraordinary. At the same time, it is important for families to plan how they will address ongoing processor maintenance after the surgery. Working with one’s insurance company, as well as the CI manufacturer, is a necessary part of the equation.

I first realized that both of our sons would need replacement parts for their cochlear implants as their external units went out of warranty. The warranty on their external processors was three years but I learned that most insurance companies do not replace a processor, even an obsolete one, until the unit is five years old. That means there is a potential two-year gap between the warranty end date and when one can expect insurance to cover replacement. There are different coverage options that may be considered including extending the warranty through the manufacturer but this particular option can be quite expensive—especially with four ears needing coverage.

I called our insurance company to ask whether they would recognize our cochlear implant manufacturer as an in-network provider, emphasizing that the company is a sole source vendor. Since there is no other entity that could be categorized as “in-network” from which to purchase parts (we can’t go to our local CVS and purchase a coil or a magnet), I argued that our CI company should be categorized as in-network provider. I was referred to the group within our insurance company that handles out-of-network requests. In speaking with the insurance company, I found that they needed a HCPCS code to replace equipment. HCPCS stands for “healthcare common procedure coding system.” There is a HCPCS for each piece of equipment. One further bit of advice—always get the name of the person you spoke to at your insurance company and also retain the date and time you spoke with them.

All three CI companies have information on HCPCS codes on their websites:

Cochlear (different pages depending on the processor) http://www.cochlear.com/wps/wcm/connect/us/recipients/nucleus-5/nucleus-5-support-and-community/insurance-support/private-insurance
http://www.cochlear.com/wps/wcm/connect/us/recipients/nucleus-6/nucleus-6-support-and-community/insurance-support/private-insurance
http://www.cochlear.com/wps/wcm/connect/us/recipients/nucleus-7/nucleus-7-support-and-community/insurance-support/private-insurance

Advanced Bionics
https://www.advancedbionics.com/content/advancedbionics/sg/en/home/support/reimbursement-services---insurance-authorization/faq-about-billing.html

MED-EL
http://s3.medel.com.s3.amazonaws.com/pdf/US_Reimbursement_Letter_of_Medical_Necessity_4.0.pdf

I forwarded the HCPCS information to our insurance company. Within a week, we received a letter granting in-network status for everything—ear-hooks, processor repairs, batteries (disposable and rechargeable), coils, cables, etc. The insurer also indicated the coverage time period and how many of each piece of equipment could be ordered during that time period.

In our case, the CI company requires that the recipient order from them directly and pay out-of-pocket, and then file a claim with insurance. It’s a bit of a hassle but ultimately worth it since almost everything was covered in full.

In filing claims, our insurance requires a diagnosis code, which you should be able to obtain from your audiologist, and the tax ID number from your CI company. Be sure and read the form you’re submitting to your insurance to be certain you’re including everything they need to process the claim. Always keep copies of everything you send to insurance for your files.

It wasn’t all smooth sailing. We had a couple of claims processed as out-of-network so it is important to check everything, comparing what was sent with what was reimbursed. It’s also important to understand your deductible and co-insurance amounts.

I ultimately asked for and was granted a case manager, who we worked with directly. Having someone to help us made everything so much easier as over time, as she then understood more about cochlear implants. Insurance companies sometimes consider cochlear implants with hearing aids, which may not be covered at the same level. Providing education is helpful and often needed.

I pursued having insurance cover the extended warranty vs. having to pay out-of-pocket each time and then get reimbursed. The company I work for is self-insured so I gathered information on all of the claims we submitted for one son, then wrote to our benefits office explaining what we (and our company) paid out-of-pocket vs. how much the extended warranty costs. There’s also the fact that having the extended warranty means much less paperwork for us and for our insurance company. By the time it was approved, our second son was eligible to receive a new processor so I didn’t pursue further this time but will next year when the second processor is out of warranty.

My mantra is that it’s always worth asking. They may say no but they also might say yes. For us, it was worth pursuing.

 

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