Cochlear implant technology has advanced significantly, candidacy has expanded, and more patients than ever have the potential to benefit. Yet many people who could be candidates still never make it to a cochlear implant evaluation. That gap was at the center of a recent Doc Talk conversation with Carrie Spangler, AuD, Executive Director of the American Cochlear Implant Alliance (ACI Alliance), hosted by Susan Good, AuD, and Camille Dunn, PhD.
Spangler officially assumed leadership of ACI Alliance in June 2026 after spending nearly three decades as an educational audiologist. She also brings a perspective that is unusual for someone leading a national cochlear implant organization: she is a bilateral cochlear implant recipient herself. Her conversation with MedAudPro offered a useful look at where cochlear implant care stands today, but more importantly, where the opportunities are to help more appropriate patients find their way into care.
Better Technology Does Not Automatically Create Better Access
One of Spangler’s clearest points was that the technology itself is only part of the equation. Cochlear implants can continue to improve, but those advances do not matter to a patient who never knows an implant may be an option, is never referred for an evaluation, assumes insurance will not cover it, or becomes lost somewhere between identification and treatment.
Spangler described the work ahead in terms of people, practice, and policy. ACI Alliance’s broader mission focuses on improving cochlear implant access through research, advocacy, and awareness, and she sees community as an important connection across all three. For practicing audiologists and other hearing healthcare providers, that means improving access does not require solving the entire problem. There are smaller points in the patient journey where individual clinicians can make a meaningful difference.
Start the Cochlear Implant Conversation Earlier
One of those opportunities is simply talking about cochlear implants sooner. Patients often have an outdated idea of who qualifies for a cochlear implant, and some still believe implants are only for people who are completely deaf or receive no benefit at all from hearing aids. Providers may also hesitate to introduce the subject because they do not want to recommend something prematurely or because they do not feel equipped to answer every question about candidacy, surgery, technology, insurance, and outcomes.
A better approach may be to introduce cochlear implantation as one of the options that could become appropriate over time. A patient whose hearing aids are still helping today can still be told that if speech understanding continues to decline, a cochlear implant evaluation may eventually be worth considering. That gives the patient time to understand the technology before they reach the point where a referral feels urgent or unexpected.
Referral Is Not the Same as Determining Candidacy
Community audiologists also do not need to determine whether someone is definitely a cochlear implant candidate before making a referral. That is what the cochlear implant evaluation is designed to determine.
During the episode, the group discussed the 60/60 guideline, a practical screening tool that can help identify adults who should be considered for a CI evaluation. The original guideline suggests referral when an adult has a better-ear pure-tone average of 60 dB HL or greater and unaided word recognition of 60% or less. It is important to understand what that guideline is and what it is not. It is a referral tool, not a final candidacy test.
Patients who meet the guideline may or may not ultimately become cochlear implant candidates, but the point is to recognize when a more complete evaluation is appropriate. ACI Alliance provides additional clinical guidance for hearing healthcare professionals who want to better understand contemporary cochlear implant candidacy and referral.
ACI Alliance Clinical Guidance
Insurance Should Not Stop the Conversation Before It Starts
Cost is another area where assumptions can interfere with referrals. Patients who have paid thousands of dollars out of pocket for hearing aids may naturally assume cochlear implants will be treated the same way, and referring clinicians may also be uncomfortable answering questions about exactly what an insurance plan will cover.
The important point is that the referring audiologist does not need to have every financial answer. Cochlear implant services are covered by many private insurance plans as well as Medicare, TRICARE, the Veterans Health Administration, and other programs, although individual benefits and requirements vary.
Medicare coverage also changed in 2022. CMS expanded its national coverage criteria so that limited benefit from amplification is now defined as 60% or less correct in the best-aided listening condition on recorded open-set sentence testing, along with the other Medicare eligibility requirements.
The practical takeaway for referring clinicians is simple: do not assume a patient cannot afford or obtain coverage for a cochlear implant. Get the patient to the appropriate CI program, where the implant team can help investigate coverage, authorization requirements, potential out-of-pocket costs, and next steps.
A New Medicaid Resource for Providers
One of the newest resources discussed during the episode is particularly timely. ACI Alliance released a Medicaid Advocacy Toolkit in August 2026 to help clinicians, CI programs, advocates, and families better understand Medicaid coverage and the potential impact of policy changes.
The free six-module resource covers Medicaid financing, cochlear implant coverage, billing and appeals, policy changes, and ways providers and advocates can engage at the state level. For practices that see Medicaid patients, this is worth bookmarking because Medicaid policy varies by state and those differences can affect evaluation, surgery, follow-up care, programming, and rehabilitation.
ACI Alliance Medicaid Advocacy Toolkit
CI Programs Can Help Build the Referral Pipeline
Improving access is not solely the responsibility of community providers. Spangler also challenged cochlear implant programs to think differently about their referral relationships. Instead of waiting for appropriate patients to appear, CI programs can reach out to the audiologists, ENT practices, hearing aid providers, and other clinicians who see those patients every day.
The goal should not simply be to generate more referrals. It should be to make referral easier. Community providers should know who to contact, what general signs should trigger a referral, what happens during the evaluation, and whether communication will come back to the referring practice. That kind of relationship can make it much easier for a clinician who does not work with cochlear implants every day to confidently tell a patient, “I think it is time for you to learn more about this.”
The Patient Perspective Matters Too
There is another side of the access discussion that deserves more attention: asking patients themselves why they hesitate. Clinicians have plenty of theories. Patients may be afraid of surgery, worried about outcomes, uncertain about insurance, concerned about losing residual hearing, waiting for newer technology, or simply not feel ready.
But assumptions about patient behavior are not enough. During the podcast, Dunn raised an important question: if the field wants to understand why cochlear implant utilization remains low, why not ask the patients who have been identified but have not moved forward?
Spangler’s own experience reinforces that point. Although she was an audiologist and understood cochlear implants professionally, she still experienced many of the same questions and concerns a patient might have before her own implantation. She described the importance of both peer support and having a care team that stayed connected beyond the surgery itself.
That perspective is an important reminder that cochlear implant care is not simply a procedure. It is a process that includes evaluation, counseling, surgery, activation, programming, rehabilitation, adjustment, and long-term support.
What Providers Can Do Now
The cochlear implant access problem is complicated, but the first steps for an individual practice do not have to be. Providers can review whether their referral criteria reflect current candidacy, pay closer attention to patients who continue to struggle despite appropriately fitted hearing aids, introduce cochlear implantation earlier, and use referral tools such as the 60/60 guideline as a prompt for further evaluation.
They can also stop feeling responsible for answering every question before making a referral. The role of the community provider is not necessarily to determine candidacy. Sometimes the most important thing that provider can do is recognize that a patient deserves the opportunity to find out.
As Dr. Carrie Spangler begins her leadership of ACI Alliance, that may be one of the most practical opportunities facing the field: making it easier for patients to move from “Could this be an option for me?” to a clinical evaluation where they can get a real answer.
Resources and References
American Cochlear Implant Alliance
Clinical, patient, advocacy, insurance, and cochlear implant education resources.
Visit ACI Alliance
ACI Alliance Clinical Guidance
Resources for understanding current cochlear implant candidacy and referral.
Determining Cochlear Implant Candidacy