Medicare Expands CI Guidelines!

It can be challenging as a provider to stay on top of all the specialties in a multi-specialty world, especially when you are not working with surgical implants or programming them every day. Changes in candidacy and patient characteristics and the overall patient journey involves more collaboration among providers than it ever has previously.

In the last several years, candidacy guidelines for cochlear implants have been expanded by the FDA several times as clinical evidence demonstrated patients with more pre-operative hearing and speech understanding were benefiting from cochlear implantation. Most health insurance plans followed FDA guidelines, but not Medicare. This put professionals in a challenging position when it came to patients with Medicare. Despite clinical candidacy being met, audiologists were forced to base their clinical decision-making on labeling and coverage instead of evidence-based clinical outcomes.

A group of Health Care Professionals in the industry created the American Cochlear Implant Alliance (ACIA) and in 2014 designed a multi-center study to explore and document outcomes in older adults who had more residual hearing that was currently allowed under Medicare coverage criteria. The study was completed with favorable results and helped ACIA formally request a reconsidering of criteria under a formal process through CMS called a National Coverage Determination.

On September 26^th, 2022, the Centers for Medicare & Medicaid Services (CMS) published details on their final decision to expand coverage for cochlear implants under Medicare. This expansion, effective immediately, provides a significant improvement in access for Medicare beneficiaries who are now able to access the benefits of cochlear implants. The specific expanded criteria can be viewed here. Most notably it expands the guidelines for speech understanding to be > 40 % and ≤ 60%.

This change will increase access to many patients who may not be getting the benefit they need out of their current hearing technology. Patients today are often bimodal and have several different multi-specialty providers across the medical realm. It’s important to understand the fundamentals of how to collaborate with other medical professionals that may be a part of the person’s care team when they are using or considering an implant.

Facilitating the continuum of care for patients creates better patient outcomes and being seen as a multi-specialty provider or a provider with multi-specialty knowledge is important for patients and for growing your clinic.