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Commercial Health Insurance and Upgrade CoverageEach commercial health insurance plan is different and has its own criteria. Therefore, it is important to check each plan regarding coverage criteria on replacement parts and upgrades. Health insurance carriers, however, may cover replacement sound processors based upon the following two criteria:
While it may be useful to include data obtained from the Nucleus 5 validation trial in a Letter of Medical Necessity, it must be determined for a specific patient whether he or she will benefit from these advancements. Among the ways to provide support for this are the following:
Medical Necessity and Commercial Health Plans
To request coverage and payment for medically necessary services, a letter of medical necessity (LMN) must be written by a currently treating medical professional familiar with the patient's medical condition and situation. Cochlear Americas cannot establish medical necessity. The following topics are usually included in an LMN:
Things to Consider
Would the upgraded sound processor and associated products allow this recipient to:
Medicare and Upgrade Coverage
Medicare classifies Cochlear™'s sound processors and associated parts and accessories as prosthetics. As such, all of cochlear's parts and accessories are subject to the durable medical equipment, prosthetics, orthotics, and supplies ("DMEPOS") requirements under Medicare. Medicare's claim Processing manual, chapter 20, section 50 (applicable to DMEPOS) provides that Medicare will cover replacement of DME equipment under the following circumstances:
Loss In circumstances of loss, Cochlear seeks supporting documentation to provide support and evidence of the loss to retain in its files. The clinic may want to obtain this information as well for its files.
b. Irreparable Wear, useful life, and Change in Patient's Condition. Medicare requires a current physician's order for claims involving replacement of equipment due to wear or a change in the patient's condition.
Irreparable Wear and Useful Life
Medicare's regulations provide that, the reasonable useful lifetime of Cochlear's product as a prosthetic device is determined through program instructions. There are no program instructions, and Cochlear™ has confirmed with CMS that the useful life of five years will apply. Computation is based on when the equipment is delivered to the beneficiary, not the age of the equipment. 42 CFR 414.210(f).
Keep in mind that replacement due to wear is not covered during the reasonable useful lifetime of the equipment; however, during the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary.
Change in the patient's condition. This is not the same standard as a "Medically Necessary" standard. To qualify for a replacement under this standard, the patient's current treating physician must issue an order that justifies the replacement of the product with another product due to an identifiable change in the patient's condition that would warrant the replacement.
Does State Medicaid Cover Upgrade Sound Processors?
Coverage for upgrade sound processors is subject to each state's Medicaid Plan guidelines, although Medicare's guidelines generally provide a good starting point for Medicaid. Check with each state's Medicaid program for their requirements, but a good practice generally would be to seek a preauthorization request, utilizing Medicare's guidelines and include a letter of medical necessity or current physician's order documenting the basis for recommending the upgrade processor to determine coverage.