This edition of the Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information that MassHealth needs to determine medical necessity for cochlear implantation for treatment of bilateral hearing loss. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.
Providers should consult MassHealth regulations at 130 CMR 433.000 (Physician Services), 426.000 (Audiologist), and 450.000 (Administrative and Billing), and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and other prior authorization (PA) requirements
Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior care organization (SCO), or a program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s, or PACE’s medical policies for covered services.
MassHealth requires PA for initial cochlear implantation surgery (CPT 69930). The initial internal and external device (CPT L8614) does not require PA if an FDA-approved device is used. Upgraded cochlear implant processors and/or replacement processors also require PA. MassHealth reviews requests for PA based on medical necessity. Please see the MassHealth audiologist regulations at 130 CMR 426.416(K) for PA requirements for replacement and upgraded external sound processors. If MassHealth approves the request, payment is still subject to all general MassHealth requirements, including member eligibility, availability of coverage through other insurance, and program restrictions.