Best Practices – Surgical Approvals, Appeals & Advocacy



By Nicole Craig, Senior Manager of Managed Care and Market Access, Cochlear Americas

Obtaining commercial insurance coverage for implantable hearing solutions can present unfamiliar challenges for your office as this may be a limited portion of your practice.  Although most commercial plans cover cochlear implants (CI) and osseointegrated bone anchored systems (Baha), each plan follows their own medical policies and prior authorization requirements.  In addition, each plan has their own coinsurance, deductibles, and out of pocket maximums based on the member’s benefit coverage.

Luckily, there are some best practices that can be implemented to improve success in navigating the insurance maze. For example, always determine if a prior authorization/precertification is required by the candidate’s health plan for their cochlear implant or osseointegrated bone anchored surgery. If so, obtain that prior authorization/pre-certification in writing where the plan allows. If available it is also a good idea to request a pre-determination.

What is the difference between a prior authorization/ pre-certification and a pre-determination?

A prior authorization (aka pre-certification) is the process to determine if the insurance company finds a service to be medically necessary.  It is mandatory for most plans for CI and Baha procedures, and a lack of prior authorization can result in a denial of coverage and reimbursement. While a prior authorization is never a guarantee of payment or reimbursement for any service, a decision which payers universally reserve the right to make after receiving and reviewing the actual claim details, it does provide some measure of assurance that you have followed the payer’s process and met their requirements.

A pre-determination of benefits is the process to determine that both an individual’s specific benefit coverage and the health plan’s medical necessity criteria is met.  It is a voluntary process, typically performed as a courtesy if available. The pre-determination process helps to avoid misunderstandings about financial liability.

Best practices:

  • When scheduling surgery, allocate enough time to allow for a response from the health plan
    • Prior authorizations typically take 15-30 days for a response from health plan
    • Pre-determinations can take up to 30 days on average
  • If prior authorization is treated as a separate process by the plan, submit the pre-determination first. Benefit coverage always supersedes medical necessity or prior authorization approval when payers evaluate services for reimbursement
  • Submit both surgery and device codes on the authorization or pre-determinationNucleus 7
  • Many plans have the ability to submit approval requests online if you are submitting them on your own
  • Always verify procedural requirements for the approval process with the health plan
  • End of year response times from health plans may be delayed.  Keep this in mind when scheduling patients and setting expectations for patients trying to optimize benefits by the end of the calendar year

What should you do if you get a denial?

When this happens, be sure to initiate the appeal.  The appeal process will vary by health plan but typically the process is outlined in the benefit handbook. As a provider, you can contribute to your patient appeal process by providing your clinical expertise. Providers should request a peer-to-peer review when available and always be sure to appeal to all levels available. Many health plans will offer three levels of appeals. Once you determine the denial reason and understand the appeal options, be sure to provide supporting documentation such as:

  • Clinical history of the patient which should include:
    • Causes of patient hearing loss
    • Length of patient’s hearing loss
    • Severity of hearing loss
    • Specific treatments tried and failed
  • FDA product approval or clearance letter (available by request through Cochlear)
  • Appeal letter to address why technology is beneficial to patient and medically necessary
  • Scientific evidence supporting the use of the technology and its applicability to your clinical recommendations for the patient’s treatment plan

Cochlear has sample appeal letters to help with crafting your appeal response. Be sure to write the letters specific to each patient and health plan denial.  Cochlear also has a variety of clinical articles to support clinical effectiveness of CI and Baha systems and are available when requested.

If an appeal is filed via fax or mail, your medical biller should follow-up within 15 days of filing to ensure that the appeal was received and to verify status.  Always maintain a “paper trail,” collecting reference numbers for every call, appeal document tracking numbers, and documenting all conversations with representatives, ensuring that names and employee ID’s are documented.

In some cases, the patient may be able to speak to their employer about offering coverage for a CI or Baha system. If employer is self-funded, the human resources department may be willing to remove the exclusions of the implantable hearing solutions or make an exception for the patient.

How are health plan medical policies developed?

Health plans develop medical policies to assist with the administration of the health benefits. The policies serve as a guideline for determining whether health services are covered, medically necessary, and fall within the health plan benefit category of covered services. Medical policies are regularly reviewed by the health plan and updated as needed. Health plans have a medical policy review process where they will review new clinical evidence about the clinical effectiveness of a procedure or technology. During the review process providers have the opportunity to review draft polices and provide comments, feedback or pertinent references to assist with the development or updating of medical policies. The volume of exception request and appeals generated through the prior authorization/pre-certification and/or the pre-determination processes can have significant impact on the timing and outcome of payer policy reviews.

How can you help improve coverage for your patients?

  • Let the Health Plan know there is a problem
    • Be sure to submit all cases for approval
    • Go all the way through the appeals process
  • The approval process not only impacts individual access, it can also prompt plans to consider changes in health plan policy, especially when a given plan routinely receives similar requests.
  • Medical policies are regularly reviewed by the health plan and updated as needed. Health plans have a medical policy review process where they will review new clinical evidence about the clinical effectiveness of a procedure or technology.
  • During the review process providers have the opportunity to review draft polices and provide comments, feedback or pertinent references to assist with the development or updating of medical policies.
  • Successful change in policy will make the process easier and less administratively burdensome for all, making services available to more patients.

How can Cochlear help?

Let Cochlear assist your practice with the authorization process.  A division of Cochlear Americas, OMS (Otologic Management Service) is a dedicated team of reimbursement specialists who are available, at no-cost, to help healthcare providers and candidates obtain the necessary insurance approval or to support appeals where coverage has been denied for Cochlear’s Nucleus® Cochlear Implants or Baha® Systems for medically qualified candidates.

As experts in medical insurance advocacy, OMS has an extensive knowledge of health insurance plans. With over 56 years combined industry experience, representatives understand that not all insurance policies are the same. OMS partners with candidates and healthcare providers to provide navigational support of the health insurance maze.

For more information on services provided by OMS, visit our webpage or contact via email at

About our guest author:

Nicole Craig is the Senior Manager of Managed Care and Market Access for Cochlear Americas. She oversees OMS and managed care contracting for Cochlear’s external DME replacement parts and accessories.

© Cochlear Limited 2019. All rights reserved. Hear now. And always and other trademarks and registered trademarks are the property of Cochlear Limited or Cochlear Bone Anchored Solutions AB. The names of actual companies and products mentioned herein may be the trademarks of their respective owners.
Information provided by Cochlear Americas regarding insurance coverage or reimbursement is provided as guidance only and is not intended as reimbursement or legal advice. Cochlear Americas makes no representation or warranty regarding such information or its completeness, accuracy, fitness for a particular purpose, or that following such guidance will result in any form of coverage or reimbursement from any insurer. Information presented is subject to change at any time. To be sure that you have the most current and applicable information available for your unique circumstances, please consult your own experts and seek your own legal advice regarding your reimbursement needs. In all cases, products or services billed must be medically necessary, actually performed and appropriately documented in the medical record.
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