Effective for dates of service beginning June 1, 2018, Harvard Pilgrim will require prior authorization for cochlear implants for members in our commercial HMO, POS, and PPO products. Harvard Pilgrim will provide coverage for unilateral or bilateral cochlear implants for adults and children and hybrid implants for adults who meet the medical review criteria.
The following codes will require prior authorization as of June 1, 2018:
- 69930 — Cochlear device implantation, with or without mastoidectomy
- 92601 — Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming
- 92602 — Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming
- 92603 — Diagnostic analysis of cochlear implant, age 7 years or older, with programming
- 92604 — Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming
- L8614 — Cochlear device/system, includes all internal and external components
- L8615 — Headset/headpiece for use with cochlear implant device, replacement
- L8616 — Microphone for use with cochlear implant device, replacement
- L8619 — Cochlear implant external speech processor, replacement
- L8628 — Cochlear implant, external controller component, replacement
Please refer to the updated Cochlear Implants Medical Review Criteria for the full criteria and details on documentation necessary to obtain prior authorization. To request prior authorization, please complete the Cochlear Implants Prior Authorization Request Form and fax it to 800-232-0816.