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«PacifiCare’s medical management guidelines represent the recommendation of the PacifiCare Medical Management Guideline (MMG) committee. They are ...»

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Majdani O, Leinung M, Rau T, et al. Demagnetization of cochlear implants and temperature changes in 3.0T MRI environment. Otolaryngol Head Neck Surg. 2008;139(6):833-839.

Makhdoum MJ, Snik AF, Van den Broek P. Cochlear implantation: a review of the literature and the Nijmegen results. J Laryngol Otol. 1997;111(11):1008-1017.

Manrique M, Cervera-Paz FJ, Huarte A, Molina M. Advantages of cochlear implantation in prelingual deaf children before 2 years of age when compared with later implantation. Laryngoscope. 2004;114(8 I):1462-1469.

Moody-Antonio S, Takayanagi S, Masuda A, et al. Improved speech perception in adult congenitally deafened cochlear implant recipients. Otol Neurotol. 2005 Jul;26(4):649-54.

Murphy J, O'Donoghue G. Bilateral cochlear implantation: an evidence-based medicine evaluation. Laryngoscope. 2007 Aug;117(8):1412-8.

National Institute for Health and Clinical Excellence (NICE). Guidance for Cochlear implants for children and adults with severe to profound deafness. January 2009.Available at: http://www.nice.org.uk/nicemedia/pdf/TA166QRG.pdf.

Accessed February, 2009.

National Institutes of Health (NIH). Cochlear Implants in Adults and Children. NIH Consensus Statement Online 1995 May 15-17;13(2):1-30. Available at: http://consensus.nih.gov/1995/1995CochlearImplants100html.htm. Accessed February 2009.

Nikolopoulos TP, Dyar D, Archbold S, ODonoghue GM. Development of spoken language grammar following cochlear implantation in prelingually deaf children. Arch Otolaryngol Head Neck Surg. 2004;130(5):629-633.

Nopp P, Schleich P, D'Haese P. Sound localization in bilateral users of MED-EL COMBI 40/40+ cochlear implants. Ear Hear. 2004 Jun;25(3):205-14.

Osberger MJ, Zimmerman-Phillips S, Barker M, Geier L. Clinical trial of the CLARION cochlear implant in children.

Ann Otol Rhinol Laryngol Suppl. 1999;177(4 pt 2):88-92.

Parkinson AJ, Arcaroli J, Staller SJ, et al. The Nucleus 24 Contour cochlear implant system: adult clinical trial results.

Ear Hear. 2002;23(1 suppl):41S-48S.

Peters BR, Litovsky R, Parkinson A, Lake J. Importance of age and postimplantation experience on speech perception measures in children with sequential bilateral cochlear implants. Otol Neurotol. 2007;28(5):649-657.

Quigley SM, Brazil-Pierce C, Dobaj H, Backous DD. Initial results of patients implanted in the MED-EL Combi 40+ investigational trial at Virginia Mason Medical Center. Adv Otorhinolaryngol. 2000;57:442-446.

Ramsden R, Greenham P, O'Driscoll M, Mawman D, Proops D, Craddock L, Fielden C, Graham J, Meerton L, Cochlear Implants - Commercial Medical Management Guideline Verschuur C, Toner J, McAnallen C, Osborne J, Doran M, Gray R, Pickerill M. Evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system. Otol Neurotol. 2005 Sep;26(5):988-98.

Rance G, Barker EJ. Speech perception in children with auditory neuropathy/dyssynchrony managed with either hearing AIDS or cochlear implants. Otol Neurotol. 2008 Feb;29(2):179-82.

Ricketts TA, Grantham DW, Ashmead DH, Haynes DS, Labadie RF. Speech recognition for unilateral and bilateral cochlear implant modes in the presence of uncorrelated noise sources. Ear Hear. 2006 Dec;27(6):763-73.

Rose M, Hey C, Kujumdshiev S, et al. Immunogenicity of pneumococcal vaccination of patients with cochlear implants.

J Infect Dis. 2004;190(3):551-557.

Santarelli R, De Filippi R, Genovese E, Arslan E. Cochlear implantation outcome in prelingually deafened young adults.

A speech perception study. Audiol Neurootol. 2008;13(4):257-65.

Schafer EC, Amlani AM, Seibold A, Shattuck PL.A meta-analytic comparison of binaural benefits between bilateral cochlear implants and bimodal stimulation. J Am Acad Audiol 2007 Oct;18(9):760-76.

Scherf F, van Deun L, van Vieringen A, et al. Hearing benefits of second-side cochlear implantation in two groups of children. Int Pediatr Otorhinolaryngol. 2007;71(12):1855-1863.

Schleich P, Nopp P, D'Haese P. Head shadow, squelch, and summation effects in bilateral users of the MED-EL COMBI 40/40+ cochlear implant. Ear Hear. 2004 Jun;25(3):197-204.

Schoen F, Mueller J, Helms J, Nopp P. Sound localization and sensitivity to interaural cues in bilateral uses of the MedEl Combi 40/40+ cochlear implant system. Otol Neurotol. 2005;26(3):429-437.

Schramm D, Fitzpatrick E, SC. Cochlear implantation for adolescents and adults with prelinguistic deafness. Otol Neurotol. 2002 Sep;23(5):698-703.

Summerfield AQ, Barton GR, Toner J, et al. Self-reported benefits from successive bilateral cochlear implantation in postlingually deafened adults: randomised controlled trial. Int J Audiol. 2006;45(suppl 1):S99-S107.

Teoh SW, Pisoni DB, Miyamoto RT. Cochlear implantation in adults with prelingual deafness. part I. Clinical results.

Laryngoscope. 2004;114(9 I):1536-1540.

Tyler RS, Gantz BJ, Rubinstein JT, Wilson BS, Parkinson AJ, Wolaver A, Preece JP, Witt S, Lowder MW. Three-month results with bilateral cochlear implants. Ear Hear. 2002 Feb;23(1 Suppl):80S-89S.

Vermeire K, Brokx JP, Wuyts FL, et al. Quality-of-life benefit from cochlear implantation in the elderly. Otol Neurotol.

2005;26(2):188-195.

Verschuur CA, Lutman ME, Ramsden R, Greenham P, O'Driscoll M. Auditory localization abilities in bilateral cochlear implant recipients. Otol Neurotol. 2005 Sep;26(5):965-71.





Vlastarakos PV, Nikolopoulos TP, Tavoulari E, et al. Auditory neuropathy: Endocochlear lesion or temporal processing impairment? Implications for diagnosis and management. Int J Pediatr Otorhinolaryngol. 2008 Aug;72(8):1135-50.

Waltzman SB, Roland JT, Cohen NL. Delayed implantation in congenitally deaf children and adults. Otol Neurotol.

Cochlear Implants - Commercial Medical Management Guideline 2002;23(3):333-340.

Wolfe J, Baker S, Caraway T, et al. 1-year postactivation results for sequentially implanted bilateral cochlear implant users. Otol Neurotol. 2007;28(5):589-596.

Zeitler DM, Kessler MA, Terushkin V, Roland TJ Jr, Svirsky MA, Lalwani AK, Waltzman SB. Speech perception benefits of sequential bilateral cochlear implantation in children and adults: a retrospective analysis. Otol Neurotol. 2008 Apr;29(3):314-25.

–  –  –

Contact Information For questions regarding this policy, send an email to the Medical Technology Interpretation Service at medical_drug_interpretation@uhc.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

modalities:

• 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)



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