Programming Codes Issued for Auditory Osseointegrated Devices (AOIs) Sound Processors

4/2/2024

As of January 1, 2024, the Centers for Medicare and Medicaid Services (CMS)  added two new CPT codes for programming sound processors for Auditory Osseointegrated Devices.  These changes are reflected in the updated CMS guidance. If a state has not implemented these changes for Medicaid services, we urge clinicians to contact their state Medicaid office and alert them to the issuance of these new CPT codes.

• CPT code 92622—Diagnostic analysis, programming, and verification of an auditory osseointegrated sound processor, any type; first 60 minutes

• CPT code 92623—Diagnostic analysis, programming, and verification of an auditory osseointegrated sound processor, any type; each additional 15 minutes (list separately in addition to code for primary procedure)

Medicare and Medicaid CI Coverage

1/5/2024

Medicare

• A federal health insurance for individuals 65 and older, and some people under 65 with certain disabilities or conditions.
• Medicare has federally set standards of coverage which means a person’s coverage will be the same regardless of state residency.  
• Medicare currently covers cochlear implants for individuals with bilateral hearing loss who meet specific audiological and other criteria.

Medicaid

• A joint federal/state program that covers specified medical costs for individuals who meet income criteria.
• The federal government has general rules that all state Medicaid programs must follow, but each state runs its own program and can set its own criteria for inclusion.
• Eligibility requirements and benefits vary state by state.
• Note that Medicaid covers for any health issue or disability that can interfere with a child’s ability to develop in a typical manner.
• Medicaid covers the CI surgery, audiology, (re)habilitation, the internal CI device, sound processor and peripherals, and other follow-up for children though specifics vary by state
• Medicaid covers CI for eligible adults in 35 states. Click the map below for a larger version.

WA State Finalizes Cochlear Implant Medicaid Expansion   

4/25/2023

Thanks to the efforts of ACI Alliance Board Member and State Champ, Dr. Daniel Zeitler, Washington State Medicaid will now provide cochlear implant coverage for adults. With the support of the Washington State Medical Association, the case was made to Members of the State legislature, the Governor’s office and Medicaid officials that the coverage is critical. This coverage will begin on July 1, 2023.

Arizona PBS Covers Efforts to Expand Medicaid to Cover Adults

3/17/2023

Due to the efforts of Arizona State Champs, the Arizona Legislature is considering expanding Medicaid to cover cochlear implants in adults. The local PBS station recently interviewed ACI Alliance Executive Director Donna Sorkin and others on the role CIs have played in their lives and the importance of this bill.

Cochlear Implants Now More Accessible to Older Adults

12/22/2022

Until recently, candidacy criteria for Medicare beneficiaries who may benefit from cochlear implantation (CI) was more stringent than the FDA guideline, typically followed by private health insurers. The narrow Medicare criteria were changed on September 26, 2022, when the Centers for Medicare & Medicaid Services (CMS) published its final rule under a process called a National Coverage Determination (NCD) to expand coverage for cochlear implants under Medicare. The CMS action facilitates an important improvement in access to CI care for older adults and confirms the benefits of broader criteria for other insurers. Read more here.

CMS Publishes Expanded Coverage for Cochlear Implants Under Medicare 

9/26/2022

On September 26, the Centers for Medicare  & Medicaid Services (CMS) published details on its decision to expand coverage for cochlear implants under Medicare.  This provides a significant improvement in access to care for older adults who are Medicare beneficiaries allowing individuals with hearing test scores between >40% and ≤60% to qualify for cochlear implantation. After reviewing the evidence submitted as part of the National Coverage Determination (NCD) process, CMS found that the evidence was sufficient to determine that cochlear implantation may be covered for a broader spectrum of hearing loss.  The policy change is effective immediately.

Specifically, CI is an appropriate treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition. Patients must meet other criteria defined by CMS as well. The final decision memorandum for the reconsideration of Cochlear Implantation was published here:  https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=306

The change was sought early on by the newly organized American Cochlear Implant Alliance with a multi-center study to explore and document outcomes in older adults who had more residual hearing than was currently allowed under Medicare coverage criteria. We approached the Centers for Medicare and Medicaid Services (CMS), requesting that they partner with us and allow Medicare expanded coverage for individuals who were part of the ACI Alliance study. Principal investigators Terry Zwolan PhD, Craig Buchman MD, and John Niparko MD led the multi-center study effort. Their thoughtful leadership over a sustained timeframe led to this important outcome. Click here  for more information on the expansion effort.

Drs. Zwolan and Buchman expressed gratitude to the CI clinicians and patients who participated in the study effort as well as CMS officials involved in the NCD process as they sought to balance care in provision of the CI intervention for older adults with the documented outcomes in communication and overall quality of life.

We will be providing materials for our ACI Alliance members who wish to help publicize this important expansion in access to CI with local media outlets, patients, and others. 

CMS Publishes Proposed Coverage Expansion for Cochlear Implants Under Medicare 

7/6/2022

Proposed Criteria Expansion

We are pleased to announce that on July 6, the Centers for Medicare & Medicaid Services (CMS) published details on its proposed coverage expansion for cochlear implants.  If adopted, Medicare would broaden candidacy criteria to allow individuals with hearing test scores of >40% and ≤60%.  After reviewing the evidence submitted as part of the National Coverage Determination (NCD) process, CMS found that the evidence was sufficient to determine that cochlear implantation may be covered for a broader spectrum of hearing loss.  Specifically, CI is an appropriate treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition. Patients must meet other criteria defined by CMS as well.

We approached the Centers for Medicare and Medicaid Services (CMS), requesting that they partner with us and allow Medicare expanded coverage for individuals who were part of the ACI Alliance study. Principal investigators Terry Zwolan PhD, Craig Buchman MD, and John Niparko MD led the multi-center study effort. Click here for more information on the expansion effort:

Decision Summary

The July 6 announcement can be found here.
In addition to the ACI Alliance request with related documentation, CMS conducted its own internal technology assessment. The Decision Summary includes reviews of published studies, a consensus statement, and a professional society guideline. Public comments provided further support for the expansion.

Support the Proposed Decision

American Cochlear Implant Alliance supports the proposed expansion criteria as presented in the July 6 Memo. There is an opportunity for 30 days (due date August 5) to comment. We encourage our members to provide a simple statement acknowledging the thorough work of CMS and supporting the expansion criteria decision as presented.  Click here for the comment area.

This is important news for the patient community and the clinicians who serve them! We are appreciative of the work of so many clinicians and researchers who contributed to this positive outcome.

Read more here.

Yes, You Can Change Medicaid 

3/2/2021
By Nichole Westin MA / Governmental Affairs Manager, ACI Alliance

All children whose families are covered by Medicaid and meet specific state candidacy criteria are eligible for cochlear implantation. CI is not currently covered for adults in all states but it can be changed. Read more here.

ACI Alliance Joins Coalition to Mitigate Cuts in Medicare Services Reimbursement 

12/9/2020

CMS is moving ahead with plans to reduce reimbursement for many categories of providers including those who provide CI services. The specific impact on CI services reductions is shown in full story below.

Reimbursement
CMS released their final Physician Fee Schedule rule for 2021. Unfortunately, they did maintain the cuts for audiologists (6%) and SLPs (9%) as well as others. Attached is a spreadsheet on specific CI related codes. The rule takes effect on January 1, 2021. The cut is due to the rule’s payment increases for evaluation and management (E/M) services that require offset to meet the budget neutrality requirements. Across the board, the conversion factor used to determine payment amounts will be decreased by almost 11%, from $36.09 in FY 2020 to $32.26 in FY 2021. The American Medical Association and other stakeholders had urged CMS to delay or phase-in the budget neutrality adjustment, but CMS did not believe they had legal authority to do so.

Read the full story here.

ACI Alliance submits comments to CMS on proposed Medicare Reimbursement reductions and support of telehealth continuance

10/5/2020

Reduction in Reimbursement Rates

With respect to specific services related to cochlear implantation (CI), the proposed cuts to the reimbursement rates for codes 92601, 92602, 92603, 92604, 69930, 69949, 69990, 92584, 92585, 92586, and 95867 will have lasting impacts. As noted in the Proposed Rule, rural and underserved communities need improved access; cutting reimbursement may force private providers to reassess accepting Medicare patients in order to remain in business. We ask that you reconsider these proposed cuts and do all you can under CMS’s current authority to eliminate or significantly reduce this financial burden.

Adding Telehealth Services Under Medicare

We appreciate the opportunity to provide comments on authorization for additional Medicare telehealth services. The Proposed Rule indicates that telehealth services that are provided as part of the cochlear implant procedure—and the rehabilitation services related to CI—are among those that will not be extended past the PHE. Having these services available virtually during the PHE has demonstrated the benefit of telehealth services for cochlear implantation for everyone – patients and providers. Not only has infection risk been mitigated during delivery of services in the COVID timeframe, outcomes of CI patients have been maintained and even improved. 

Read full letter here.

ACI Alliance Seeks to Protect Access to CI and Osseointegrated Devices in Medicare Hearing Health Legislation

9/22/2020

ACI Alliance is promoting specific language to clarify that legislation to cover hearings aids for certain Medicare beneficiaries (i.e., H.R. 4618) does not inadvertently hurt patients with severe or profound hearing loss who would be better served by a referral for evaluation for cochlear implants (CIs) or osseointegrated devices. The inclusion of hearing aid coverage in this legislation is an important step to improving hearing health under the Medicare program, and we remain committed to working with Congress and other advocacy groups to ensure this bill meets the individualized needs of Medicare beneficiaries.

Congress has already recognized the importance of cochlear implants and osseointegrated devices for appropriate Medicare beneficiaries as the procedures are covered by Medicare. ACI Alliance is committed to working with policymakers to include the legislative language in H.R. 4618 and prevent any negative unintended consequences for patients.

Fact Sheet: Cochlear Implants, Hearing Aids, and Older Adults.

Click here for full media alert.

ITEM Coalition Includes ACI Alliance Priorities in CMS Letter

8/1/20219

ACI Alliance participates in coalitions with other organizations in healthcare or disability fields to expand opportunities to address public policy issues. In August 2019, the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition included difficulty in securing long-term cochlear implant equipment under Medicaid in a letter to CMS regarding the Patients over Paperwork Initiative.  The letter recommend that CMS should prioritize simplified and transparent coverage policies on cochlear implantation when reviewing state plan amendments and waiver requests. To read the letter in its entirety, please click here.

ACI Alliance Survey of Medicaid Coverage and Barriers to Access

3/1/20219

ACI Alliance surveyed cochlear implant clinics regarding Medicaid coverage of cochlear implantation in their state. The results were published in Otology & Neurotology with data on state Medicaid programs’ coverage of cochlear implants (CI) for adults and children and barriers that may contribute to full access. While State Medicaid programs are allowed flexibility in their coverage policies, Medicaid programs in all states must cover conditions that impact on a child's growth and development under Medicaid because of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT). Because pediatric hearing loss is considered a risk factor that may negatively impact a child's normal development, cochlear implants in children are covered in all 50 states and the District of Columbia. CI coverage for adults under Medicaid is optional and determined by each state with an estimated 60% of states providing coverage for adults. Since cochlear implantation involves services beyond the surgery, we also examined patient access to the continuum of related services including audiology, therapy, and equipment replacement. To access the study and read the full results, please click here.

Ensuring that patients have appropriate access to insurance coverage

8/14/2018

Ensuring that patients have appropriate access to insurance coverage is a key organizational priority. All 50 states and Washington, DC cover children under Medicaid, but the nature of coverage as well as the payment amount varies greatly. We have surveyed CI clinics and found that there are access to care issues created by state regulations that limit sound process replacements, numbers of batteries allowed, and sufficient coverage of therapy. We believe that these regulations interfere with Congressional intent on ensuring appropriate services for Medicaid covered children under federal law. We will be discussing the findings with appropriate Federal policy-makers in the Fall 2018. 

CI coverage of adults under Medicaid is optional under Federal law; whether and how adults are covered is determined by the individual states. An estimated 60% of states cover eligible adults for cochlear implants under Medicaid. ACI Alliance was contacted by Disability Rights Maryland (DRM), an organization that advocates for the legal rights of Maryland residents with disabilities. DRM was interested in pursuing CI coverage for adults under Maryland Medicaid. ACI Alliance provided information and supported the effort. The State of Maryland made the decision to cover cochlear implants for adults under Medicaid starting in July 2018. Read our comments on the proposed rule HERE.

ACI Alliance visited with staff at Centers for Medicare & Medicaid Services (CMS)

10/30/2018

As part of our ongoing advocacy and education efforts on Medicaid, the ACI Alliance visited with staff at Centers for Medicare & Medicaid Services (CMS) as well as with the Majority and Minority staff for the House Energy and Commerce Committee and Senate Finance Committee.  We shared information on cochlear implants and the life-changing benefits that they provide for children and adults.  In addition, we discussed ongoing access issues Medicaid patients and providers face including reimbursement, replacement policies for sound processors and other equipment, caps on rehabilitative therapies, and MCOs. We encourage our members to contact us at info@acialliance.org to add to our collective knowledge on how Medicaid is serving children and adults who have or need cochlear implants.