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Cochlear Implant Revision Performed as a Simultaneous Bilateral Procedure
It’s a fact of life. Hardware fails, and cochlear implants are no exception to this rule. Several studies indicate that cochlear implant revision surgery is as safe as initial implantation in both adults and children.
- Côté M, Ferron P, Bergeron F, Bussières R., Cochlear reimplantation: causes of failure, outcomes, and audiologic performance, Laryngoscope, 117(7):1225-35 (July 2007). 43 implant revision cases over 5.5 years, concluding “Medical and audiologic outcomes are generally excellent. Revision implantation appears to be a safe and effective procedure.”
- Migirov L, Taitelbaum-Swead R, Hildesheimer M, Kronenberg J., Revision surgeries in cochlear implant patients: a review of 45 cases, Eur Arch Otorhinolaryngol, 264(1):3-7 (January 2007). 45 implant revision cases, concluding “The post-revision audiological benefit was unchanged or improved compared to the initial implantation values in all reimplanted patients.”
- Fayad JN, Eisenberg LS, Gillinger M, Winter M, Martinez AS, Luxford WM., Clincial performance of children following revision surgery for a cochlear implant, Otolaryngol Head Neck Surg., 134(3):379-84 (March 2006). 28 implant revision cases, concluding “The majority of children recover their pre-revision clinical performance.”
- Lassig AA, Zwolan TA, Telian SA., Cochlear implant failures and revision., Otol Neurotol. 26(4):624-34 (July 2005). 58 implant revision cases, concluding: “Management of implant failures and performance revision surgery are becoming increasingly important in cochlear implant programs. Outcomes are generally excellent. Revision implantation is a safe and appropriate procedure that should be pursued in a timely fashion when patients experience cochlear implant failure.”
- Fayad JN, Baino T, Parisier SC., Revision cochlear implant surgery: causes and outcome, Otolaryngol Head Neck Surg., 131(4):429-32. (Oct. 2004). 43 implant revision cases, concluding “Cochlear re-implantation is technically feasible and allows for continued auditory stimulation.”
- Buchman CA, Higgins CA, Cullen R, Pillsbury HC., Revision cochlear implant surgery in adult patients with suspected device malfunction, Otol Neurotol., 25(4):504-10; discussion 510 (July 2004). 33 implant revision cases, concluding “Revision cochlear implantation should be considered in patients significantly affected by intolerable auditory and/or non-auditory symptoms or when performance issues have been documented.”
The Lassig study, the largest of the six, found that 5.1% of cochlear implant surgeries at a fairly large cochlear implant center were revision procedures, with documented or suspected device failure causing the need for the revision surgery in almost two-thirds of the cases.
Many individuals, when only unilaterally implanted and facing the need to replace that implant, desire to undergo the procedure as a simultaneous bilateral implantation. This choice requires only one session under general anesthesia, one recovery period, and allows the patient to combine audiology appointments rather than going through two complete sets of follow-up. The result is the patient will have two functioning implants, and if one should fail in the future, the other (most likely) will continue to be operational while the failing implant is being dealt with.
If your insurer is Blue Cross, Blue Shield, CIGNA, Medica, Health Partners, Tufts, or Harvard Pilgrim, the option of simultaneous bilateral cochlear implantation should automatically be available to you, provided that you meet the medical necessity criteria established by these organizations. Although these criteria differ from insurer to insurer and are still somewhat in flux, the key that most insurers who have dropped the claim that bilateral cochlear implantation is experimental/investigational seem to be looking at is whether the CI+HA bimodal speech recognition test results are the same, worse, or substantially better than the CI alone speech recognition test results.
For people who are not fortunate enough to have an insurer who covers bilateral cochlear implantation without requiring an appeal, these are the insurance options facing that individual:
1) Replace the failing side; don't do anything with second side.
Pros: Provided that your insurance does not contain a blanket exclusion refusing to pay for any cochlear implant related services, this is the fastest of the options with respect to getting the failing side back up to full operation.
Cons: A second surgical procedure is required to deal with the unimplanted side. Sequential bilateral implantation costs approximately $22,000 more than simultaneous bilateral implantation, so if what you pay is based on a percentage of what the insurer pays, this option may cost you more $$. Also, if you do the two surgeries in two separate insurance years, you will have to pay your deductable again.
2) Wait for approval for both sides, and then undergo a simultaneous bilateral procedure.
Pros: This is the least expensive option, with only one surgery required.
Cons: This type of appeal can take up to four months before approval is obtained. If your doctor is willing to write a letter stating that the standard timeframe required for an appeal will jeopardize your health because of the failed/failing device, you may be able to shorten that window to approximately three weeks. Insurer’s are more likely to approve a simultaneous bilateral on appeal because of the lower overall cost, described above.
3) Proceed with simultaneous bilateral, appeal second side after.
Pros: Same as #2 with shorter timeframe to surgery. In some cases the hospital or surgeon may require a substantial deposit since you are proceeding without insurance approval in advance. In other cases, the implant manufacturer may be willing to offer to guarantee payment for the second device due to the failure of the initial device.
Cons: Insurer may refuse payment for the second side after the fact. The case then becomes a post-service appeal, which can take up to 14 months to resolve (as opposed to the 4 month average for pre-service appeals noted in item #2). Nationwide, across all medical conditions the odds of winning a pre-service appeal are 80% and the odds of winning a post-service appeal are 36%. The Let Them Hear Foundation is fully committed to assist with this type of post service bilateral cochlear implant appeal case; however, there is a risk that the patient will end up paying for the second side if the appeal does not resolve in their favor.
In the end, any of these options are perfectly viable and the decision lies with the service provider’s comfort level in offering the bilateral implantation procedure in a simultaneous format combined with the patient’s weighing of the financial risk of proceeding without approval vs. the need for a speedy resolution vs. the desire to accomplish this implantation in a single surgical procedure.
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