NC Medicaid: Cochlear And Auditory Brainstem Implants, 1A-4.

NC MedicaidCochlear and AuditoryBrainstem ImplantsMedicaid and Health ChoiceClinical Coverage Policy No: 1A-4Amended Date: December 04, 2019To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits andservices available on or after implementation, please contact your PHP.Table of Contents1.0Description of the Procedure, Product, or Service . 11.1Definitions . 12.0Eligibility Requirements . 12.1Provisions. 12.1.1 General . 12.2Special Provisions . 22.2.1 EPSDT Special Provision: Exception to Policy Limitations for a MedicaidBeneficiary under 21 Years of Age . 22.2.2 EPSDT does not apply to NCHC beneficiaries . 32.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through18 years of age . 33.0When the Procedure, Product, or Service Is Covered . 33.1General Criteria Covered . 33.2Specific Criteria Covered. 33.2.1 Specific criteria covered by both Medicaid and NCHC . 33.2.2 Cochlear Implant. 33.2.3 Auditory Brainstem Implants. 43.2.4 Upgrades and Maintenance . 53.2.5 Contralateral Cochlear Implant . 53.2.6 Simultaneous Bilateral Cochlear Implants. 53.2.7 Diagnostic Analysis and Programming . 63.2.8 Medicaid Additional Criteria Covered. 63.2.9 NCHC Additional Criteria Covered . 64.0When the Procedure, Product, or Service Is Not Covered . 64.1General Criteria Not Covered . 64.2Specific Criteria Not Covered. 64.2.1 Specific Criteria Not Covered by both Medicaid and NCHC. 64.2.2 Medicaid Additional Criteria Not Covered. 74.2.3 NCHC Additional Criteria Not Covered. 75.0Requirements for and Limitations on Coverage . 75.1Prior Approval . 75.1.1 Cochlear Implant. 75.1.2 Auditory Brainstem Implant . 75.1.3 Upgrades and Maintenance . 75.1.4 Contralateral Cochlear Implant . 85.1.5 Simultaneous Bilateral Cochlear Implants. 85.1.6 Aural Rehabilitation. 85.1.7 Diagnostic Analysis and Programming . 819K26i

NC MedicaidCochlear and AuditoryBrainstem Implants5.2Medicaid and Health ChoiceClinical Coverage Policy No: 1A-4Amended Date: December 04, 20195.1.8 Replacement Parts and Repairs. 8Prior Approval Requirements . 85.2.1 General . 86.0Providers Eligible to Bill for the Procedure, Product, or Service . 86.1Provider Qualifications and Occupational Licensing Entity Regulations. 96.2Provider Certifications . 97.0Additional Requirements . 97.1Compliance . 98.0Policy Implementation/Revision Information. 10Attachment A: Claims-Related Information . 12A.Claim Type . 12B.International Classification of Diseases and Related Health Problems, Tenth Revisions,Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) . 12C.Code(s) . 12D.Modifiers. 13E.Billing Units. 13F.Place of Service . 13G.Co-payments . 13H.Reimbursement . 1319K26ii

NC MedicaidCochlear and AuditoryBrainstem ImplantsMedicaid and Health ChoiceClinical Coverage Policy No: 1A-4Amended Date: December 04, 2019Related Clinical Coverage PoliciesRefer to https://medicaid.ncdhhs.gov/ for the related coverage policies listed below:13A, Cochlear and Auditory Brainstem Implant External Parts Replacement and Repair10A, Outpatient Specialized Therapies1.0Description of the Procedure, Product, or ServiceA cochlear implant is an electronic medical device designed to restore some ability to perceivesounds and understand speech by individuals with moderate to profound hearing loss. A cochlearimplant bypasses damaged hair cells in the cochlea and stimulates the remaining nerve fibersdirectly through the application of electrical current. Cochlear implants have external parts andinternal (surgically implanted) parts that work together to allow the user to perceive sound.An auditory brainstem implant (ABI) is a modification of the cochlear implant in which thestimulating electrode is placed directly into the brain.After surgery, these two devices require activation, fitting of essential external components,programming, and rehabilitation for proper function and benefit.1.1 DefinitionsNone Apply.2.0Eligibility Requirements2.1Provisions2.1.1General(The term “General” found throughout this policy applies to all Medicaid andNCHC policies)a. An eligible beneficiary shall be enrolled in either:1. the NC Medicaid Program (Medicaid is NC Medicaid program, unlesscontext clearly indicates otherwise); or2. the NC Health Choice (NCHC is NC Health Choice program, unlesscontext clearly indicates otherwise) Program on the date of service andshall meet the criteria in Section 3.0 of this policy.b. Provider(s) shall verify each Medicaid or NCHC beneficiary’s eligibilityeach time a service is rendered.c. The Medicaid beneficiary may have service restrictions due to theireligibility category that would make them ineligible for this service.Following is only one of the eligibility and other requirements forparticipation in the NCHC Program under GS 108A-70.21(a): Children mustbe between the ages of 6 through 18 (The term “Specific” found throughoutthis policy only applies to this policy)a. MedicaidNone Apply.CPT codes, descriptors, and other data only are copyright 2018 American Medical Association.All rights reserved. Applicable FARS/DFARS apply.19K261

NC MedicaidCochlear and AuditoryBrainstem ImplantsMedicaid and Health ChoiceClinical Coverage Policy No: 1A-4Amended Date: December 04, 2019b. NCHCNone Apply.2.2Special Provisions2.2.1EPSDT Special Provision: Exception to Policy Limitations for aMedicaid Beneficiary under 21 Years of Agea. 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is afederal Medicaid requirement that requires the state Medicaid agency tocover services, products, or procedures for Medicaid beneficiary under 21years of age if the service is medically necessary health care to correct orameliorate a defect, physical or mental illness, or a condition [healthproblem] identified through a screening examination (includes anyevaluation by a physician or other licensed practitioner).This means EPSDT covers most of the medical or remedial care a childneeds to improve or maintain his or her health in the best condition possible,compensate for a health problem, prevent it from worsening, or prevent thedevelopment of additional health problems.Medically necessary services will be provided in the most economic mode,as long as the treatment made available is similarly efficacious to the servicerequested by the beneficiary’s physician, therapist, or other licensedpractitioner; the determination process does not delay the delivery of theneeded service; and the determination does not limit the beneficiary’s right toa free choice of providers.EPSDT does not require the state Medicaid agency to provide any service,product or procedure:1. that is unsafe, ineffective, or experimental or investigational.2. that is not medical in nature or not generally recognized as an acceptedmethod of medical practice or treatment.Service limitations on scope, amount, duration, frequency, location ofservice, and other specific criteria described in clinical coverage policies maybe exceeded or may not apply as long as the provider’s documentation showsthat the requested service is medically necessary “to correct or ameliorate adefect, physical or mental illness, or a condition” [health problem]; that is,provider documentation shows how the service, product, or procedure meetsall EPSDT criteria, including to correct or improve or maintain thebeneficiary’s health in the best condition possible, compensate for a healthproblem, prevent it from worsening, or prevent the development of additionalhealth problems.b. EPSDT and Prior Approval Requirements19K262

NC MedicaidCochlear and AuditoryBrainstem ImplantsMedicaid and Health ChoiceClinical Coverage Policy No: 1A-4Amended Date: December 04, 20191. If the service, product, or procedure requires prior approval, the fact thatthe beneficiary is under 21 years of age does NOT eliminate therequirement for prior approval.2. IMPORTANT ADDITIONAL INFORMATION about EPSDT andprior approval is found in the NCTracks Provider Claims and BillingAssistance Guide, and on the EPSDT provider page. The Web addressesare specified below.NCTracks Provider Claims and Billing Assistance roviders/providermanuals.htmlEPSDT provider page: https://medicaid.ncdhhs.gov/2.2.2EPSDT does not apply to NCHC beneficiaries2.2.3Health Choice Special Provision for a Health Choice Beneficiary age 6through 18 years of ageNC Medicaid shall deny the claim for coverage for an NCHC beneficiary whodoes not meet the criteria within Section 3.0 of this policy. Only servicesincluded under the NCHC State Plan and the NC Medicaid clinical coveragepolicies, service definitions, or billing codes are covered for an NCHCbeneficiary.3.0When the Procedure, Product, or Service Is CoveredNote: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations forMedicaid Beneficiaries under 21 Years of Age.3.1General Criteria CoveredMedicaid and NCHC shall cover the procedure, product, or service related to this policywhen medically necessary, and:a.the procedure, product, or service is individualized, specific, and consistent withsymptoms or confirmed diagnosis of the illness or injury under treatment, and notin excess of the beneficiary’s needs;b.the procedure, product, or service can be safely furnished, and no equally effectiveand more conservative or less costly treatment is available statewide; andc.the procedure, product, or service is furnished in a manner not primarily intendedfor the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.3.2Specific Criteria Covered3.2.1Specific criteria covered by both Medicaid and NCHC3.2.2Cochlear Implanta. Medicaid and NCHC shall cover cochlear implants and aural rehabilitationfor Medicaid beneficiaries ages 12 months of age and older and for NCHCbeneficiaries ages 6 years through 18 years when ALL of the followingrequirements are met and are documented in the health record:19K263