Are you in the market for a cochlear implant? Does Medicare Cover Cochlear Implants for you? If you are and you’d like to know, then in this article we will discuss what a cochlear implant is, how must it costs and various details in regards to cochlear implant medicare coverage.
What Is A Cochlear Implant And What Does It Do?
Cochlear implants are a Class III medical device designed for people who cannot derive adequate benefit from traditional hearing aids. They are comprised of two main parts: the internal cochlear stimulator, which is surgically placed under the skin, and the external speech processor, which contains microphones to capture sound.
Usually, the placement of the internal device is done as an outpatient procedure. An incision is made behind the ear, and a physician (typically an otologist or neuro-otologist) drills into the temporal bone to obtain access to the cochlea. The electrode array is inserted into the cochlea, and the device is placed on the skull. Though the surgery may sound intense, most patients go home the same day and often have minimal discomfort post-operatively. A few weeks after surgery, once the incision has healed and swelling has minimized, the patient will visit the audiologist for an activation appointment where the external processor is programmed.
The audiologist will ask the patient to provide loudness judgments across the electrode array by presenting sounds via the proprietary software. When the microphones on the processor are enabled, the processor picks up acoustic sound from the environment and converts it to electrical impulses. The electrode array inside the cochlea essentially takes the place of the damaged hair cells by sending these electrical impulses to the auditory nerve and, in turn, to the brain.
Magnets on the headpiece portion of the external processor and the internal device align antennae, allowing the external and internal portions to communicate with one another. Most processors are worn on the ear like a hearing aid, though each manufacturer has options to wear the processor off the ear if needed, while still keeping the headpiece in place.
There are often several appointments early on to fine-tune the sound quality from the cochlear implant. It is important to note that cochlear implants do not sound like hearing aids, and they do not sound like normal hearing. They do restore access to sound, and many people find great success with cochlear implants who are really struggling with hearing aids. Children who are implanted early can develop completely normal speech and language and attend mainstream schools.
It is critical to wear a cochlear implant during all waking hours in order to allow the brain to adapt to the new sound, and many centers will recommend specific aural rehabilitation activities in addition to daily listening to improve performance with a cochlear implant.
Who Is A Candidate For A Cochlear Implant?
First, candidacy is based on two main factors: the patient’s audiogram and their discrimination ability with appropriately fit hearing aids. Generally, an adult patient must have considerable hearing loss (moderate to profound) and poor discrimination ability with hearing aids. The patient must also be healthy enough for surgery and have an etiology of hearing loss that permits implantation (i.e., present and patent cochlea).
Specific criteria for cochlear implants can be confusing because there are several sources of information. One set of published criteria is the FDA criteria, which differs slightly by the cochlear implant manufacturer. When manufacturers submit a device to the FDA for approval, clinical trials are conducted with a specific patient population. The published criteria are based on this study population and are likely the most conservative because manufacturers often recruit patients with more hearing loss to test their devices. Research is increasingly showing greater benefit and performance with a cochlear implant in individuals with more residual hearing. Still, clinical trials are expensive and time-consuming, so the FDA criteria may remain somewhat stagnant.
Medical providers have the ability to recommend devices or prescribe medication “off-label,” meaning the patient does not meet the FDA criteria for the device or medication, but the provider feels that the patient would benefit clinically. Off-label use is very common in all branches of medicine. Providers often make off-label recommendations when research and patient experience show clinical benefit.
Because of this, cochlear implant teams and centers may have their own set of criteria for hearing test results and aided discrimination scores that differ from what is published by the FDA and tends to be less stringent.
Does Medicare Cover Cochlear Implants?
Should you meet the FDA and/or center-specific criteria for cochlear implantation, the next hurdle is getting approval from your insurance company. Between the surgery and the actual devices, cochlear implantation is not something most patients are able to afford out of pocket. Fortunately, most insurers cover the majority of the cost if you meet the criteria, which would be outlined in a letter of medical necessity (LMN) written by your provider(s).
We’re going to talk specifically about Medicare coverage for cochlear implants as they are the largest insurer for people over age 65, which is a large population of individuals with hearing loss who may meet candidacy criteria for cochlear implants. Patients have been implanted and found success with their devices well into their 90s, so it isn’t too late to pursue this option if hearing aids are no longer enough.
The surgery and device are usually covered under Medicare Part B. Still; costs can vary depending on supplemental insurance, the type of facility where you undergo the procedure, and specific fees charged by your provider(s). The out-of-pocket cost could be up to 20% of the costs of your cochlear implant, and your deductible would apply. You can work with your provider to determine your expenses prior to surgery.
What Are The Guidelines For Qualifying For A Cochlear Implant?
In September of 2022, Medicare-approved expanded criteria for cochlear implantation in older adults. Previously, patients with Medicare had to score below 40% on a test of word discrimination with appropriately fit hearing aids in order to qualify for a cochlear implant. A multi-center, multi-year study was conducted to show that patients who did not quite meet this 40% cutoff score were still good candidates and that they performed significantly better with a cochlear implant than they had with their hearing aids.
The new criteria specify that patients who score below 60%, in addition to a diagnosis of bilateral moderate-to-profound sensorineural hearing loss, are eligible for a cochlear implant. In addition to the audiogram and test scores, patients must be healthy enough to undergo the surgery and be cognitively able to use the device and undergo rehabilitation and listening practice after surgery.
While the criteria specify that you must have bilateral sensorineural hearing loss, Medicare will cover one cochlear implant. It is not abnormal for adults to receive one implant and continue to use a hearing aid on the other ear. Some adults choose to have their other ear implanted, though this would depend on insurance coverage and personal preference. You will determine with your provider which ear should be implanted based on performance with hearing aids and whether there is an anatomical or medical reason to implant one ear over the other.
Some centers will recommend relying on the cochlear implant alone in the first weeks or even months after activation, while others will encourage continued use of your contralateral hearing aid. There are several resources available for auditory rehabilitation with your cochlear implant to try to teach your brain to interpret the new input.
Are There Continued Costs After Surgery?
There are three FDA-approved cochlear implant manufacturers: Advanced Bionics, Cochlear, and Med-El. All three companies offer a ten-year warranty for their internal devices and a five-year warranty for external devices. Once you are outside of those warranties, you would work with your provider and insurer to cover repairs or replacements. It is the practice of many cochlear implant centers to encourage patients to choose which of the three devices they want to use. There are advantages to all three, and each company has printed materials, web-based resources, and access to patients using the device to who you can speak to during your decision-making process.
If you think you might be a candidate for a cochlear implant, speak to your provider about undergoing candidacy testing. Similar to the known delay in pursuing hearing aids, almost all patients who have gotten a cochlear implant say they wish they had done it sooner. It is generally a very under-utilized medical device despite its proven success.
Erin Edwards received her Doctor of Audiology degree from Towson University in 2015 and her Ph.D. in Education and Leadership from Pacific University in 2022. She has worked with patients of all ages in a variety of settings and has a specific interest in cochlear implants, the relationship of hearing loss and dementia, and interdisciplinary healthcare.