Center for the Future of the Health Professions Feb. 2025 digest
Posted: February 20, 2025
The Center for the Future of the Health Professions, dedicated to providing policymakers and healthcare stakeholders with comprehensive data for effective planning, presents its second op-ed column for 2025 focusing on the revolutionary journey of cochlear implants.
This comprehensive article explores cochlear implants technology. Hearing impairment affects over 1.5 billion people globally, with at least 700 million requiring hearing rehabilitation. Since their development in the mid-20th century, cochlear implants have emerged as a revolutionary solution for severe to profound hearing loss, evolving from a concept once dismissed as a “fool’s dream” to becoming one of modern medicine’s most successful neural prostheses. These sophisticated biomedical devices bypass damaged inner ear structures to directly stimulate the auditory nerve, enabling sound perception in ways conventional hearing aids cannot. With over 1 million successful implantations worldwide and expanding candidacy criteria, cochlear implants continue to transform lives despite persistent challenges in accessibility and healthcare coverage.
Our two guest authors are:
Soha Garadat, PhD, an associate professor of audiology and speech-language pathology at A.T. Still University’s Arizona School of Health Sciences. She earned her master’s in clinical audiology and PhD in audiology/physiology from the University of Wisconsin–Madison, followed by a NIH/NIDCD-funded postdoctoral fellowship at the University of Michigan’s Kresge Hearing Research Institute. Dr. Garadat’s research centers on optimizing cochlear implant outcomes and understanding performance variations. She serves on editorial boards for major audiology journals and the RNID Innovation Seed Fund review panel. As a former MED-EL consultant, she brings international expertise in cochlear implant research and clinical applications.
Shelley Baltodano, AuD, who serves as an assistant professor and clinical coordinator in audiology and speech-language pathology at A.T. Still University’s Arizona School of Health Sciences. After earning degrees from the University of South Carolina and University of Alabama, she completed her doctor of audiology at ATSU-ASHS and fellowship at the House Ear Clinic. Her expertise spans auditory implants, neurofibromatosis type 2 treatment, and various clinical specialties. She brings extensive experience mentoring audiology students while maintaining a diverse clinical practice including newborn screening and educational audiology.
We welcome your feedback and comments on this month’s digest at cfhp@atsu.edu.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
From skepticism to success: The revolutionary journey of cochlear implants
Hearing impairment affects over 1.5 billion people globally, with projections indicating this number will surge to 2.5 billion by 2050. Among these individuals, at least 700 million will need hearing rehabilitation services, underscoring the critical importance of accessible interventions.1
Cochlear implants are advanced biomedical devices designed to restore hearing in individuals with severe to profound sensorineural hearing loss who receive little to no benefit from conventional amplification. Unlike hearing aids, which amplify sound, cochlear implants bypass damaged inner ear structures and directly stimulate the auditory nerve using precisely controlled electric pulses. This system consists of external and surgically implanted internal components. The external unit captures sound, encodes it, and transmits it to the internal implant via a radio frequency link. The implant converts these signals into electrical pulses that stimulate the auditory nerve, allowing the brain to perceive sound.
The evolution of cochlear implant technology
The development of cochlear implants began in the mid-20th century, with significant advancements in the 1980s and 1990s. Initially, early designs faced skepticism, as many prominent scientists questioned their ability to replicate the intricate biophysics of the inner ear and raised concerns about their long-term efficacy, dismissing the concept as a “fool’s dream.”
One skeptical remark captured the prevailing doubts: “I have the utmost admiration for the courage of those surgeons who have implanted humans. I will admit that we need a new operation in otology, but I am afraid this is not it.”
Despite these early doubts, the journey continued, driving design, functionality, and surgical technique advancements. These advancements have resulted in smaller, more sophisticated devices and remarkable outcomes, with some recipients achieving 100% accuracy on sentence recognition tests.2
These images illustrate the evolution of cochlear implants over time. The first image shows the bulky design of early implants, while the second displays the compact, discreet devices available today.
Image adapted from Adapted from the Encyclopedia of Australian Science and Innovation (link)
Cochlear implants today: A standard of care
Cochlear implants are widely accepted and recognized as one of the most successful neural prostheses in modern medicine, becoming the standard of care for individuals with severe to profound hearing loss.3 As of July 2022, over 1 million devices have been successfully implanted worldwide. Approximately 118,100 adults and 65,000 children have received these life-changing prostheses in the United States.4
Expanding candidacy: Who can benefit?
Since the FDA first approved cochlear implants, candidacy criteria have continuously expanded – initially, only adults with profound deafness and no word recognition qualified. Over time, the criteria expanded to include adults with more residual hearing and up to 60% speech recognition. In 2019, the FDA approved cochlear implants for individuals five years of age and older with single-sided deafness or asymmetrical hearing loss, recognizing the importance of binaural hearing for speech perception and localization.In 2020, the minimum implantation age was lowered from 12 months to 9 months, reinforcing the importance of early intervention. Overall, these expanded criteria have allowed more children and adults to regain functional hearing and improve their quality of life. Additionally, implantation for unique etiologies has proven effective in restoring hearing when alternative treatments are unsatisfactory, further expanding the applications of cochlear implants. 5
Why early access to sound matters
Approximately 1 in 1,000 newborns in the U.S. is born with profound deafness, and another two to three in 1,000 babies are born with partial hearing loss, placing many children at risk for delayed auditory and language development. The first three years of life represent a critical period for speech and language acquisition, as the brain is most receptive to forming the neural connections essential for language development. Specific neural pathways in the auditory cortex become hard-wired with consistent auditory exposure. This critical period is time-sensitive; in the absence of sensory input, the organization of these pathways can be altered, increasing the risk of abnormal central maturation in children with hearing loss.6
Early intervention is important for improving speech and language outcomes and reducing long-term societal costs. Research indicates that early cochlear implantation leads to superior outcomes compared to hearing aids in children with congenital deafness. By minimizing language delays, early implantation supports age-appropriate speech and language development, reducing the need for speech therapy, hearing intervention, and long-term hearing services. The educational benefits are also substantial, with higher rates of mainstream school placements and less reliance on special education resources.7
Are cochlear implants as effective as they claim to be?
Absolutely! Cochlear implants have transformed the lives of thousands, enabling better communication and seamless integration into mainstream education and the workforce. Research shows cochlear implantation improves speech perception, workplace performance, and overall quality of life. Studies also show receiving a cochlear implant early, rather than waiting for complete deafness, minimizes the adverse effects of hearing loss and prevents communication difficulties that can lead to isolation and emotional distress. By enhancing communication and reducing social barriers, cochlear implants improve quality of life in ways far beyond hearing alone.8
Engineering and speech processing advances have improved cochlear implant sound quality, enabling more individuals to regain effective communication and greater independence. These implants are provided in different stimulation modalities: unilaterally (one ear), bimodally (used in combination with a hearing aid in the other ear), or bilaterally (both ears). Bilateral implantation offers several advantages, including improved sound quality, better speech perception in noise, reduced listening effort, and better sound localization. As awareness of cochlear implant benefits grows, more adults are seeking audiologists’ expertise to determine whether cochlear implantation could enhance their everyday communication.
Barriers to access in cochlear implantation
Despite their proven efficacy, cochlear implants remain underutilized due to several barriers.
Financial barriers and insurance coverage
One of the primary factors influencing access to cochlear implants is the financial burden associated with the procedure. A single device typically costs between $30,000 and $50,000.9 When factoring in surgery and rehabilitation, the total cost can reach up to $100,000, making these devices significantly more expensive than conventional hearing aids.10 This places considerable strain on individuals and public healthcare systems. Although expanded candidacy criteria have made cochlear implants accessible to more individuals with impairment, insurance limitations restrict access for many eligible candidates. Before 2022, Medicare limited coverage to individuals with 40% or lower sentence recognition scores, excluding many individuals who could have benefited.
Policy changes and expanded coverage
Advocacy efforts led by organizations such as the American Cochlear Implant Alliance and prominent researchers in the field resulted in a landmark policy change by the Centers for Medicare and Medicaid Services (CMS). Citing strong clinical evidence, CMS issued a Decision Memorandum on September 26, 2022, expanding cochlear implantation coverage under National Coverage Determination (NCD) 50.3. With this update, Medicare now covers cochlear implantation for individuals with bilateral moderate-to-profound sensorineural hearing loss who receive limited benefit from amplification, defined as sentence recognition scores of ≤60%, which aligns with current candidacy criteria. This policy shift has significantly improved access to cochlear implants for older adults who previously did not qualify.
Geographical disparities and logistical challenges
Beyond financial barriers, geographic factors can pose additional challenges. Specialized implant centers are primarily located in urban areas, forcing individuals in underserved areas to travel long distances for evaluation, surgery, and follow-up care. The associated costs, time commitment, and logistical difficulties may discourage eligible candidates from pursuing implantation.
The role of telemedicine in expanding access
Telemedicine has emerged as a promising solution for overcoming geographical barriers. Remote programming for cochlear implants has advanced significantly, particularly after the COVID-19 pandemic. Initially, patients had to visit satellite clinics for remote programming. However, recent advancements in digital healthcare have allowed them to receive care from the comfort of their homes using smartphone applications and secure internet connections. This advancement has improved accessibility by reducing travel time, costs, and inconvenience while delivering care comparable to in-person visits. As telehealth services expand and gain broader insurance coverage, remote programming can further improve access to cochlear implant services, ensuring more individuals receive the care they need.
The evolving role of cochlear implant audiologists
Audiologists face increasing challenges in cochlear implant care, including a shortage of trained professionals and inadequate reimbursement. These challenges make it difficult to meet the needs of a rapidly expanding patient population.
Audiologists play a key role in cochlear implantation, from assessing candidacy and programming devices to offering lifelong support. In recent years, the expansion of candidacy criteria has increased the demand for audiologists with expertise in implantable hearing technologies. However, the number of recipients is expected to outpace the availability of trained professionals, particularly as cases become more complex. Despite this growing demand, there remains a critical shortage of audiologists nationwide, particularly those specializing in cochlear implantation.11
Candidacy criteria have expanded over the past five years, yet research quantifying the workforce gap in this specialized field is limited. Moreover, recent research indicates not all practicing audiologists are adequately trained and competent in cochlear implant programming.12 This shortage of well-trained cochlear implant audiologists has been a long-standing issue, partly due to gaps in specialized education. Although academic programs include cochlear implant coursework, few offer dedicated lab components providing essential hands-on training. Variability in training across academic programs further exacerbates this issue, creating an additional barrier to meeting the increasing demand for expert cochlear implant care. Addressing this gap requires a stronger emphasis on specialized education and clinical training to ensure audiologists are fully prepared to meet the evolving needs of the cochlear implant field.13
As demand for cochlear implant services rises, reimbursement policies also fail to keep pace, making it more difficult to provide comprehensive care and limiting patient access.14 An audiologist may spend 90 minutes programming a patient’s device. In 2025, the Medicare fee schedule for audiologists includes a reimbursement rate of $107.85 for diagnostic analysis of a cochlear implant (CPT code 92601). This amount does not reflect the expertise or time required.
Candidacy evaluations and device programming are just the tip of the iceberg in cochlear implant care. Successful outcomes depend on extensive patient counseling and training, requiring significant provider time. However, there are no specific billing codes associated with aural rehabilitation for audiology, which is the most time-consuming part of implantation and ensures successful patient outcomes. This gap leads to billing inconsistencies, frequent claim denials, and further financial challenges for providers.15
According to the American Speech-Language-Hearing Association, audiology services saw a cumulative 2-5% decrease in Medicare payments beginning in 2024. With many private insurance providers following suit, this trend can threaten the long-term sustainability of audiological services. Despite continued advocacy from organizations like the American Speech-Language-Hearing Association, reimbursement structures remain inadequate, leading to financial strain on providers, higher out-of-pocket patient costs, and potential limitations on service quality and access to this technology.16
The ongoing cochlear implant journey
Cochlear implants are a transformative invention that restores hearing and enhances education, productivity, and quality of life, emphasizing their importance as a public health priority.
However, barriers to access continue to limit their full potential. Advocacy, policy reforms, and investments in telemedicine are critical to maximizing their reach and impact. With ongoing research and technological advancements, cochlear implants continue to transform auditory rehabilitation, offering renewed hope to millions worldwide.
References
- World Health Organization. Deafness and Hearing Loss. 2023. Accessed February 1, 2025. https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss
- Gifford RH, Shallop JK, Peterson AM. Speech recognition materials and ceiling effects: considerations for cochlear implant programs. Audiol Neurootol. 2008;13(3):193-205.
- Wilson BS, Dorman MF, Woldorff MG, Tucci DL. Cochlear implants matching the prosthesis to the brain and facilitating desired plastic changes in brain function. Prog Brain Res. 2011;194:117-129.
- National Institute on Deafness and Other Communication Disorders. Quick statistics about hearing. 2022. Accessed February 1, 2025. https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing.
- Varadarajan VV, Sydlowski SA, Li MM, Anne S, Adunka OF. Evolving criteria for adult and pediatric cochlear implantation. Ear Nose Throat J. 2021;100(1):31-37.
- Sharma A, Nash AA, Dorman M. Cortical development, plasticity, and re-organization in children with cochlear implants. J Commun Disord. 2009;42(4):272-279.
- Colletti L, Mandalà M, Shannon RV. Left temporal bone density and right ear dominance in cochlear implantation. Otol Neurotol. 2011;32(3):309-315.
- Olgun Y, Arayici ME, İncesulu A, et al. Evaluation of the impact of cochlear implantation on patients’ working life: A cross-sectional study. Healthcare (Basel). 2024;12(5):566.
- Nadège C, Valérie G, Laura F, et al. The cost of cochlear implantation: a review of methodological considerations. Int J Otolaryngol. 2011;2011:210838.
- Soundly. Cochlear Implant Costs: What You Need to Know. August 7, 2023. Accessed February 1, 2025. https://www.soundly.com/blog/cochlear-implant-cost
- Planey AM. Audiologist availability and supply in the United States: A multi-scale spatial and political economic analysis. Soc Sci Med. 2019;222:216-224.
- Neukam JD, Kunnath AJ, Patro A, Gifford RH, Haynes DS, Moberly AC, Tamati TN. Barriers to Cochlear Implant Uptake in Adults: A Scoping Review. Otol Neurotol. 2024;45(10):e679-e686.
- Parisier SC. Cochlear implants: growing pains. Laryngoscope. 2003;113(9):1470-1472.
- Garber S, Ridgely MS, Bradley M, Chin KW. Payment under public and private insurance and access to cochlear implants. Arch Otolaryngol Head Neck Surg. 2002;128(10):1145-1152.
- Hall MW, Prentiss SM, Coto J, Zwolan TA, Holcomb MA. Decoding billing practices in cochlear implant programs. Ear Hear. 2022;43(2):477-48626.
- American Speech-Language-Hearing Association. 2024 Medicare Physician Fee Schedule: Audiology Services. ASHA Advocacy. Published November 3, 2023. Accessed February 1, 2025. https://www.asha.org/siteassets/reimbursement/2024-medicare-fee-schedule-for-audiologists.pdf