The American Academy of Audiology commends the Centers for Medicare & Medicaid Services (CMS) on the decision to expand the eligibility criteria for cochlear implementation (CI) coverage for adults with aided sentence recognition scores of up to 60%.
CMS released today the final decision memo announcing the change in national coverage determination for CI. The memo delineates the CMS conclusion that sufficient evidence exists to support coverage for the treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. CMS defines limited benefit from amplification by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.
CMS elaborates further within the decision memo (and summary) on eligibility for CI coverage. CMS stipulates that patients must meet all of the following criteria:
- Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from appropriate hearing (or vibrotactile) aids;
- Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
- Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
- No contraindications to surgery; and
- The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
On March 1, 2022, CMS initiated a national coverage analysis (NCA) to consider the proposed expansion of CI coverage for adults with aided sentence recognition scores of up to 60%. The Academy convened a task force to review the NCA and evidence to support the expansion and reached out to the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) to explore collaboration. The Academy and AAO-HNS submitted comments jointly to support the expanded coverage. The comments contended that CI is a well-established, non-experimental intervention that is appropriate for adults, including Medicare beneficiaries, who receive limited benefit from hearing aids.
On July 6, 2022, CMS issued a proposed decision memorandum and announced an additional 30-day comment period. The Academy was pleased to see that CMS was proposing to move forward with the expanded coverage. Again, the Academy submitted brief comments in support of the decision.
For additional information about the NCA and decision memo, visit the CMS website at NCA – Cochlear Implantation (CAG-00107R) – Decision Memo (cms.gov)
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