Does Medicare Cover Cochlear Implants? The Criteria and What You Pay

What are Medicare's criteria for a cochlear implant?

Medicare's national coverage determination for cochlear implantation sets the criteria, effective for services performed on or after September 26, 2022. The covered indication is bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification.

The determination defines limited benefit with one test: scores of 60% correct or less on recorded tests of open-set sentence recognition, taken “in the best-aided listening condition”.

It then lists the criteria a beneficiary must meet. In the source's wording:

• Hearing: bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from appropriate hearing (or vibrotactile) aids.
• Rehabilitation: cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation.
• Ear and nerve: freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system.
• Surgery: no contraindications to surgery.
• Device: the device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.

This page reports the criteria as CMS publishes them. It makes no assessment of any one person's case.

What if a person meets only some of the criteria?

The determination answers in two steps. Section C says Medicare beneficiaries not meeting all of the coverage criteria listed in Section B are deemed not eligible for Medicare coverage, except as described in Section D.

Section D opens a narrow route through research. CMS may provide coverage for beneficiaries outside the criteria when the implant is performed in an FDA-approved category B investigational device exemption clinical trial, as defined at 42 CFR 405.201. Coverage may also come as a routine cost in clinical trials under section 310.1 of the National Coverage Determinations Manual. CMS records that the determination was last reviewed in September 2022.

Which part of Medicare pays, and what do you owe?

Part A or Part B pays, depending on the setting. Medicare.gov says either part covers a surgically implanted prosthetic device, depending on if the surgery takes place in an inpatient or outpatient setting.

For Part B, the 2026 amounts on Medicare.gov are:

• Deductible: $283 before Original Medicare starts to pay, owed once each year.
• Coinsurance: 20% of the Medicare-approved amount for a prosthetic device, once the deductible is met.

Medicare.gov applies coinsurance to each Medicare-covered service or item. Medicare also pays for a prosthetic device only when it comes from a supplier that participates in Medicare.

What copayment does the outpatient hospital file list?

For an outpatient implant in a hospital, the CMS OPPS Addendum B for October 2026 prints three copayment fields on the row for surgery code 69930:

• National unadjusted copayment: $6,942.79.
• Minimum unadjusted copayment: $6,737.26.
• Adjusted beneficiary copayment: $1,736.00.

The Note column of the same row explains the adjusted figure: “Copayments capped at inpatient deductible of $1,736.00.”

The same row carries status indicator J1, APC 5166 and a national payment rate of $33,686.28. All of these are national CMS figures from a fee schedule. We report each field as CMS prints it. We derive no personal copayment from them, and none from the 20% rate either.

Where do the surgery center and surgeon amounts fit?

An ambulatory surgical center is paid from a separate CMS file. Its October 2026 row for code 69930 shows payment indicator J8, the device-intensive flag and a national payment rate of $29,768.66. That file publishes no copayment for the row, so those cells stay empty.

The surgeon is paid under the Physician Fee Schedule. For 69930, the national facility amount is $1,059.81: the file's 31.73 total relative value units multiplied by its conversion factor of 33.4009. It is the national amount before geographic adjustment, and it sits apart from the facility payment.

The hospital rate and the surgery center rate describe two different settings. They are alternatives, so neither is added to the other or to the surgeon's amount. A full breakdown by setting, programming code and Medicaid year is on cochlear implant cost.

Related pages

Medicare rules for hearing aids are on does Medicare cover hearing aids. Replacement processors and parts are on cochlear implant processor replacement cost, and bone-anchored devices on BAHA hearing aids.