Author: Clinical Policy and Programs
Changes to two clinical coverage policies – 2A-1, Acute Inpatient Hospital Services and 1A-4, Cochlear and Auditory Brainstem Implants – will soon become effective.
2A-1, Acute Inpatient Hospital Services
Effective April 1, 2018, North Carolina Medicaid will revise Clinical Coverage Policy 2A-1, Acute Inpatient Hospital Services, to align with 42 CFR 456.60, Certification and recertification of need for inpatient care. 42 CFR 456.60 specifies that only a physician may perform the initial certification for admission.
1A-4, Cochlear and Auditory Brainstem Implants
Effective May 1, 2018, North Carolina Medicaid will revise Clinical Coverage Policy 1A-4, Cochlear and Auditory Brainstem Implants. The following changes will be made:
- Medicaid coverage for cochlear implantation and aural rehabilitation will be expanded. Beneficiaries ages 12 months and older will be eligible when criteria are met. The coverage requirement for the level of hearing loss for the ear to be implanted will be changed to “greater than or equal to 70 dB HL.”
- Medicaid coverage allows an adult to receive a cochlear implant replacement when medically necessary. Medicaid and NCHC shall cover the replacement of an existing traditional cochlear implant as medically necessary when any of the following criteria are met:
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- The currently used component is no longer functional, cannot be repaired and there is no evidence to suggest that the device has been abused or neglected
- The currently used component renders the implanted beneficiary unable to adequately or safely perform age-appropriate activities of daily living, or
- The current technology has been made obsolete by the manufacturer.
The adult beneficiary will be able to receive the necessary diagnostic analysis and programming of the new device per policy as needed.
- Medicaid coverage allows an adult to receive a contralateral cochlear implant when criteria are met.
- Postoperatively, Medicaid will cover diagnostic analysis and programming as defined in the policy for an adult that receives cochlear implants.
- ICD 10 code H90.5 was deleted. ICD 10 codes H90.A21, H90.A22, H90.41 and H90.42 were added.
Clinical Policy and Programs
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