Cochlear implants can be life-changing, allowing deaf children and adults as well as those with severe hearing problems to obtain auditory functioning when hearing aids are ineffective. But the devices are extremely expensive -- and restricted in their qualification for health insurance coverage.
A cochlear implant is a complex, surgically implanted medical device that bypasses damaged structures in the inner ear and stimulates the auditory nerve. With an external portion that sits behind the ear and a second portion that is surgically placed under the skin, it often is called the bionic ear, according to the National Institute on Deafness and Other Communication Disorders (NIDCD).
NIDCD estimates the cost for a cochlear implant procedure at roughly $60,000. Health insurance coverage for cochlear implants has improved in recent years, partly thanks to Americans with Disabilities Act, according to the American Speech-Language-Hearing Association (ASHA).
More than 90 percent of commercial health plans cover the implants at varying levels, according to Gallaudet University's Laurent Clerc National Deaf Education Center, with Aetna, Blue Cross Blue Shield and Prudential offering the most comprehensive coverage. According to ASHA, federal law requires that all state Medicaid agencies provide coverage for cochlear implants for people ages 1 to 21. Most state Medicaid programs provide benefits for adults as well.
However, cochlear implants are complex instruments that involve lifetime maintenance, and few insurance plans cover all repairs associated with them. For example, CIGNA does provide insurance coverage for cochlear implants for adults and children over age 1, but only if it's determined there's "limited or no benefit" from hearing aids. Furthermore, CIGNA does not cover upgrading a cochlear implant if it is functioning properly, unless it's medically necessary. In other words, if technology improves, your insurance may not pay for a newer, better implant.
Given the potential costs, it's critical to confirm that your insurance plan covers cochlear implants and how much it will cover. You also must obtain formal preauthorization, according to Cochlear Americas, which manufactures the devices. To obtain preauthorization, work with your health care provider and insurance company to obtain a predetermination letter and letter of medical necessity. Your health care provider then will follow up with the insurance company every seven to 10 days until a response is received, according to Cochlear Americas. If your insurance company denies your request, check to see which appeal options are available.