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Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at email@example.com with the word "Medical" in the subject line.
Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.
Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.
HCPCS Code Section L8614 Cochlear device, includes all internal and external components L8615 Headset/headpiece for Use with cochlear implant device, replacement L8616 Microphone for Use with cochlear implant device, replacement L8617 Transmitting coil for Use with cochlear implant device, replacement L8618 Transmitter cable for Use with cochlear implant device, replacement L8619 Cochlear implant external speech processor, replacement L8621 Zinc air battery for Use with cochlear implant device, replacement, each
Cochlear Implants - Commercial Medical Management Guideline
L8622 Alkaline battery for Use with cochlear implant device, any size, replacement, each L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each L8624 Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each CPT Code Section 69930 Cochlear device implantation, with or without mastoidectomy 92601 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming 92602 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming 92603 Diagnostic analysis of cochlear implant, age 7 years or older; with programming 92604 Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming 92626 Evaluation of auditory rehabilitation status; first hour 92627 Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure) 92630 Auditory rehabilitation; pre-lingual hearing loss 92633 Auditory rehabilitation; post-lingual hearing loss ICD-9 Diagnosis Codes 387.1 Otosclerosis involving oval window, obliterative 387.2 Cochlear otosclerosis 388.00 Unspecified degenerative and vascular disorders 388.01 Presbyacusis 388.12 Noise-induced hearing loss 388.2 Unspecified sudden hearing loss 388.45 Acquired auditory processing disorder 388.5 Disorders of acoustic nerve 389.10 Unspecified sensorineural hearing loss 389.12 Neural hearing loss, bilateral 389.15 Sensorineural hearing loss, unilateral 389.16 Sensorineural hearing loss, asymmetrical 389.18 Sensorineural hearing loss, bilateral 389.22 Mixed hearing loss, bilateral 744.02 Other congenital anomaly of external ear causing impairment of hearing Cochlear Implants - Commercial Medical Management Guideline 744.03 Congenital anomaly of middle ear, except ossicles, causing impairment of hearing 744.04 Congenital anomalies of ear ossicles 744.05 Congenital anomalies of inner ear This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation.
Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Confidential and Proprietary, © UnitedHealthcare, Inc. 2009 Cochlear Implants - Commercial Medical Management Guideline TITLE: Cognitive Rehabilitation Authorized By: Medical Management Guideline Committee
Adoption Date: 08/11/09 Revision Date:
Disclaimer This medical management guideline represents the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. It is based on the MMG committee's review of the available evidence as of the date of this medical management guideline.
This medical management guideline contains clinical practice and utilization criteria to assist professionals in PacifiCare’s medical management practice when making medical necessity determinations prior to, subsequent to, or concurrent with the provisions of health care services. This medical management guideline is intended to support consistent, appropriate medical necessity determinations, but it does not replace an individualized case-by-case review and medical necessity determination for each PacifiCare member.
Member benefit coverage and limitations may vary based on the member’s benefit plan.
This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Cognitive Rehabilitation- Commercial Medical Management Guideline This policy describes the use of cognitive rehabilitation and coma stimulation therapies that attempt to improve impaired cognitive functions following injury to the brain from physical trauma or brain damage due to stroke and other conditions.
Coverage All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.
Coverage Rationale Cognitive rehabilitation is proven for the treatment of traumatic brain injury and brain injury due to stroke, aneurysm, anoxia, encephalitis, brain tumors, and brain toxins when the patient can interactively participate in the program (e.g. is not comatose or at a level of consciousness that would preclude such interaction). The treatment regimen usually includes one of the following
• Specific interventions for functional communication deficits, including pragmatic conversational skills, or
• Compensatory memory strategy training.
Cognitive rehabilitation is unproven for the treatment of cerebral palsy, Down syndrome, Alzheimer's disease, attention deficit hyperactivity disorder, developmental disorders such as autism, and Parkinson's disease.
Coma stimulation is unproven for the treatment of comatose or minimally responsive patients who have sustained a brain injury due to limited evidence with overall poor quality in methodology and design, and diversity in reporting outcome measures.
See the medical policy titled, Sensory Integration and Coordination Therapy for information regarding the use of sensory integration therapy for treatment of learning disabilities, developmental delays, and sensory integration disorders.
Centers for Medicare and Medicaid Services (CMS): Medicare does not have a national coverage policy specific to cognitive rehabilitation. Local Coverage Determinations (LCDs) for Physical Medicine and Rehabilitation that address cognitive rehabilitation exist. Compliance with these policies is required where applicable. These LCDs are available at http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=P Local articles that address cognitive rehabilitation also exist. See local articles for Revised Provider Education: Guidance on Appropriate Inpatient Rehabilitation Admissions at http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from=alphaarticle&letter=R. (Accessed April 6, 2009)