Access Expands for Cochlear Implants: CMS Decision Affects Eligibility Criteria The Centers for Medicare and Medicaid Services (CMS) issued a coverage decision on April 5 that will increase access to cochlear implants by expanding the eligibility criteria. The decision was based on a 2004 request from Cochlear Americas to the CMS to make a national coverage determination (NCD) to change ... Policy Analysis
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Policy Analysis  |   May 01, 2005
Access Expands for Cochlear Implants: CMS Decision Affects Eligibility Criteria
Author Notes
  • Ingrida Lusis, director of federal and political affairs, can be reached at ilusis@asha.org.
    Ingrida Lusis, director of federal and political affairs, can be reached at ilusis@asha.org.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   May 01, 2005
Access Expands for Cochlear Implants: CMS Decision Affects Eligibility Criteria
The ASHA Leader, May 2005, Vol. 10, 1-10. doi:10.1044/leader.PA1.10062005.1
The ASHA Leader, May 2005, Vol. 10, 1-10. doi:10.1044/leader.PA1.10062005.1
The Centers for Medicare and Medicaid Services (CMS) issued a coverage decision on April 5 that will increase access to cochlear implants by expanding the eligibility criteria. The decision was based on a 2004 request from Cochlear Americas to the CMS to make a national coverage determination (NCD) to change Medicare coverage requirements to match U.S. Food and Drug Administration (FDA) labeling indications for approval of implantation of a cochlear implant. ASHA provided comments in support of expanding eligibility requirements. The decision referenced ASHA’s recommendation that by adopting FDA’s allowance of higher sentence recognition scores, more adults can benefit from cochlear implants.
In its decision memo CMS states, “The evidence is adequate to conclude that cochlear implantation is reasonable and necessary for treatment of bilateral pre- or postlinguistic, sensorineural, moderate to profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of < 40% correct in the best aided listening condition on tape recorded test of open-set sentence cognition. CMS will also cover cochlear implantation for beneficiaries with hearing test scores of > 40% and < 60%, if the provider is participating in and the patient is enrolled in an FDA or CMS approved clinical trial.”
Currently, Medicare covers cochlear implants when speech recognition scores are 30% or less. In making the changes in eligibility criteria, CMS stated that since its original coverage decision, cochlear implant devices have improved and that FDA has made changes in the degree of hearing loss for which it will approve the use of cochlear implants. It is expected that information on the Medicare effective date will be published within the next 30 days.
In making the change, CMS provided two comment periods. Over 160 comments were received in support of expanding eligibility criteria. Comments were received from audiologists, speech-language pathologists, professional organizations, universities, cochlear implant centers, and cochlear implant recipients. According to CMS, several comments discussed the need for intense aural rehabilitation and that lack of access to rehabilitation affects overall outcomes. CMS responded that the comments reinforce the agency’s concern that rehabilitation is a necessary and required service in order for the cochlear implant to be effective.
Cochlear implants were first covered for Medicare adults in 1986. The agency’s initial policy decision provided coverage of cochlear implants for patients at least 18 years of age, whose hearing loss was postlingual, profound, bilateral, sensorineural deafness and who had a stimulable auditory nerve and who lacked the unaided residual auditory ability to detect sound. The eligibility criteria were changed in 1998, and were based on a 1995 NIH Consensus Statement that included updated audiologic criteria for implantation of adults.
This favorable Medicare eligibility ruling follows ASHA’s successful advocacy efforts late last year that created a new Ambulatory Payment Classification (APC) for cochlear implant follow-up and programming, and significantly increased reimbursement for these procedures under the 2005 Hospital Outpatient Prospective Payment System (OPPS). ASHA’s continued lobbying also helped to increase reimbursement rates for cochlear implantation by almost 15% for a median payment rate of $26,000.
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May 2005
Volume 10, Issue 6