Cochlear implantation is growing. Candidacy has expanded, awareness of hearing health is increasing, and more patients are receiving implants. Yet growth in the number of procedures does not necessarily mean the cochlear implant access problem is being solved.
In a recent MedAudPro Doc Talk conversation, Daniel Zeitler, MD, Chair of the American Cochlear Implant Alliance, described the challenge as a “numerator versus denominator” issue. The numerator, representing the number of patients receiving cochlear implants, continues to rise. The denominator, representing the number of people who may qualify for evaluation and treatment, is expanding even faster. And that matters because implant volume can increase while a significant percentage of eligible patients still never receive an evaluation, reach a cochlear implant center, or move forward with treatment.
Why Does Cochlear Implant Access Remain Limited?
Cochlear implant access remains a challenge because the number of potentially eligible patients is growing faster than the number receiving implants. Limited provider awareness, inconsistent referral practices, patient misconceptions, concerns about surgery, and capacity limitations within cochlear implant programs can all prevent candidates from reaching evaluation and treatment. In this context, cochlear implant access means more than insurance coverage. It includes identifying appropriate candidates, referring them for evaluation, helping them make an informed decision, and providing timely surgical and follow-up care.
Key Takeaways
- More patients are receiving cochlear implants, but the number of potentially eligible candidates is growing even faster.
- Expanded candidacy does not automatically lead to earlier identification, referral, evaluation, or treatment.
- Provider knowledge, patient perceptions, referral pathways, and clinical capacity all influence cochlear implant access.
- Improving access will require both greater awareness and care models capable of supporting a larger candidate population.
Why Has Expanded Cochlear Implant Candidacy Not Solved Access?
The potential cochlear implant population has grown for several reasons.
Clinical evidence and regulatory indications have expanded consideration of cochlear implantation to additional patient populations, including some adults with single-sided deafness and asymmetric hearing loss. Separately, Medicare broadened its national coverage criteria in 2022 for qualifying adults with bilateral moderate-to-profound sensorineural hearing loss. Under the revised policy, limited benefit from amplification is defined as a score of 60% or less in the best-aided listening condition on recorded tests of open-set sentence recognition.
These changes have created opportunities for more patients to benefit from cochlear implantation. They have also made the access challenge more visible. During the podcast, Dr. Zeitler estimated that approximately 12% to 13% of patients who qualified under more traditional Medicare criteria ultimately received a cochlear implant. As candidacy expands, he explained, the percentage of the total eligible population receiving treatment may become even smaller, despite continued growth in the number of implants performed. In other words, the field may be treating more people while falling further behind the total need.
Why Are Eligible Cochlear Implant Candidates Not Being Referred?
Limited access is often described as a patient-awareness problem, but the information gap exists at several points in the care pathway. Primary care physicians, neurologists, geriatricians, audiologists, otolaryngologists, and other healthcare professionals may have different levels of familiarity with current cochlear implant candidacy and referral guidance. That becomes more challenging as candidacy recommendations, payer policies, and available treatment options continue to evolve.
A patient may meet the criteria for an evaluation and still remain in conventional hearing aid care for years without a meaningful discussion about cochlear implantation. That does not necessarily reflect poor care. In many cases, it reflects a rapidly changing clinical landscape and a lack of clear, consistent communication across the broader hearing healthcare system.
What Is the 60/60 Cochlear Implant Referral Guideline?
The original 60/60 guideline was developed as a practical screening tool to help clinicians identify adults who should be referred for a traditional cochlear implant candidacy evaluation.
Under the guideline, referral was recommended when a patient had:
- A better-ear unaided word-recognition score of 60% or less
- A better-ear unaided pure-tone average of 60 dB HL or greater
The guideline was designed to support referral, not to make a final candidacy determination. More recent American Cochlear Implant Alliance recommendations emphasize treating each ear individually and using a revised 60/60 guideline as part of a broader, individualized approach to referral and candidacy evaluation. Patients who fall outside a single screening rule may still warrant referral when hearing aids provide limited functional benefit or when hearing loss is significantly affecting communication and daily life. Referral tools are valuable, but they only work when providers know about them and feel confident using them.
Why Do Patients Delay Cochlear Implant Evaluation?
Patients also bring their own assumptions and concerns to the decision. Many still perceive a cochlear implant as a last resort rather than one option within a continuum of hearing care. Some worry about surgery. Others are concerned about the visibility of the external technology or have an outdated understanding of who cochlear implants are intended to help.
Hearing loss can make these conversations particularly difficult because it often progresses gradually. Patients adapt to reduced hearing over time. Families repeat themselves, change how they communicate, or begin handling situations the patient once managed independently. Providers may also continue adjusting hearing aids as hearing declines. Because these changes happen slowly, the point at which hearing aids are no longer providing sufficient benefit may not be obvious.
During the conversation, Dr. Zeitler described a patient who delayed treatment for years because of concerns about surgery. After receiving a cochlear implant, the patient questioned why the decision had taken so long. No single story represents every patient, but the example illustrates an important access barrier: identifying a candidate does not automatically move that person from awareness to action.
Patients also need clear counseling about:
- What a cochlear implant evaluation involves
- What surgery and rehabilitation may require
- What outcomes can reasonably be expected
- What alternatives remain available
- Why an evaluation does not obligate them to proceed
Can Cochlear Implant Programs Handle Increased Demand?
Public discussion of hearing health has increased substantially. Over-the-counter hearing aids, broader media attention, and conversations about the relationship between hearing and overall health are helping bring hearing loss into the mainstream.
That attention may encourage more people to recognize hearing difficulty and seek care earlier. It may also create greater awareness of cochlear implants among patients who receive limited benefit from hearing aids.
But greater awareness introduces another question: Is the field prepared for what happens if significantly more patients enter the system? Cochlear implant care has traditionally relied on a series of in-person evaluations, counseling appointments, surgical visits, activation appointments, programming sessions, and follow-up care. These services remain essential, but many programs are already managing limited clinical capacity. If awareness and referrals increase substantially, traditional care models may not scale indefinitely.
During the podcast, Dr. Zeitler discussed the potential importance of:
- Reducing unnecessary visits
- Expanding appropriate remote care
- Strengthening relationships between cochlear implant centers and community audiologists
- Reconsidering how patients move through evaluation and follow-up
This is not about lowering the standard of care. It is about determining which parts of care must remain consistent, which can be personalized, and how technology and professional partnerships can make specialized services available to more patients.
What Could Improve Cochlear Implant Access?
No single policy, technology, referral guideline, or awareness campaign will solve cochlear implant access.
Meaningful progress will require several parts of the system to move together:
- Earlier recognition of patients receiving limited benefit from hearing aids
- Greater provider familiarity with referral recommendations
- Clearer patient education and counseling
- Stronger referral relationships between community providers and implant centers
- Clinical workflows that can support a larger candidate population
- Care models that maintain quality while using provider time more effectively
Expanded candidacy creates opportunity, but opportunity is not the same as access.
The question is no longer simply whether more patients qualify for cochlear implants. It is whether hearing healthcare can identify those patients, help them understand their options, guide them through the decision, and provide the care they need once they enter the system.
The full MedAudPro Doc Talk conversation with Daniel Zeitler, MD, examines the forces expanding cochlear implant candidacy, the barriers that continue to limit access, and how the field may need to prepare for greater demand.
References
- Zeitler DM. Discussion of cochlear implant market forces, candidacy expansion, access barriers, patient decision-making, and future care delivery models. MedAudPro Doc Talk Podcast, CI Special Series, Episode 1. [May 5, 2026]
- Zwolan TA, Schvartz-Leyzac KC, Pleasant T. Development of a 60/60 guideline for referring adults for a traditional cochlear implant candidacy evaluation. Otology & Neurotology. 2020;41(7):895–900. doi:10.1097/MAO.0000000000002664.
- Zeitler DM, et al. American Cochlear Implant Alliance Task Force recommendations for determining cochlear implant candidacy in adults. Laryngoscope. 2024;134(Suppl 2):S1–S14. doi:10.1002/lary.30879.
- Centers for Medicare & Medicaid Services. National Coverage Determination 50.3: Cochlear Implantation. Revised coverage criteria effective September 26, 2022.
- Dillon MT, et al. American Cochlear Implant Alliance Task Force guidelines for clinical assessment and management of adult cochlear implantation for single-sided deafness. Ear and Hearing. 2022;43(6):1605–1619. doi:10.1097/AUD.0000000000001261.
Frequently Asked Questions
Yes. The number of patients receiving cochlear implants continues to grow. However, the population that may qualify for evaluation has also expanded, so increased implant volume does not necessarily mean that a larger percentage of eligible patients is receiving treatment.
Candidates may be missed because of limited awareness of current referral guidance, continued hearing aid use despite limited benefit, patient concerns about surgery, outdated perceptions of cochlear implants, and inconsistent referral pathways.
No. A cochlear implant evaluation helps determine whether a patient may benefit from implantation and gives the patient an opportunity to understand the treatment, potential outcomes, limitations, and alternatives. It does not obligate the patient to proceed.
The 60/60 guideline provides one screening approach, but current recommendations emphasize evaluating each ear individually. Referral should also be considered when hearing aids provide limited functional benefit, even when a patient does not fit a single screening rule.