By Wendy J. Huinck, Simone Naber, Stef Groenewoud and Adriana L. Smit

Cochlear implantation (CI) is an effective treatment for severe hearing loss with major benefits for quality of life. Untreated hearing loss has far‑reaching consequences: children with congenital deafness show altered development with long‑term effects on language and speech, while adults who lose hearing often become socially isolated despite having developed language. These impacts remain underestimated and contributed to the development of the WHO’s World Report on Hearing.

Because CI can restore access to sound, its impact is substantial. In children it enables speech‑language development and participation in mainstream education; in adults it supports continued social and societal engagement. Access to this care is therefore essential. Given the clear advantages of two‑ear (bilateral) hearing, access should logically include both ears. Yet in several Western European countries, bilateral CI is reimbursed for children but only one implant for adults, despite strong evidence that adults too benefit from a second implant through better localization, improved speech understanding, reduced listening effort, and higher quality of life. Limiting reimbursement to one ear is difficult to justify and creates inequity.

Restricting treatment to just one ear also has consequences:

• The indication for the first CI depends on the other ear. When only one CI is reimbursed, clinicians and patients may be compelled to choose a less than optimal ear due to concerns about residual hearing or balance function.
• Young adults turning eighteen may feel pressured to decide quickly because reimbursement ends, even when postponement would be clinically appropriate. These are policy dilemmas, not medical ones.
• Not treating an ear has long‑term effects. Unstimulated ears lose auditory capacity, reducing the chance of successful CI rehabilitation later.

This means that a second implant is not a simple repeat of the first. Outcomes depend on factors such as duration of deafness, surgical technique, residual hearing, cognition, vestibular function, and social context. These interact, making outcomes impossible to capture in a single measure.

We therefore argue that bilateral CI should be considered standard care for adults with severe bilateral hearing loss for whom a second CI provides added value compared to a hearing aid in the contralateral ear. The CI indication should from the outset be aimed at achieving an optimal bilateral hearing outcome. This means that any second implant should be regarded as an integral part of the overall treatment of both ears, rather than as a separate procedure. For some adults this will result in sequential bilateral CI, while for others it will result in a bimodal fitting, with a CI in one ear and an optimally fitted hearing aid in the other.

To achieve this, current policy must be revised: reimbursement for bilateral cochlear implantation should not be assessed solely as a medical device for improved hearing, but as an intervention that affects multiple domains of life. Broader evaluation frameworks are needed—ones that also take into account non‑medical benefits, the impact on family and society, and real‑world experiences. Such an approach enables more individualized assessment and supports shared decision‑making, placing personal benefits and limitations at the center. It is also a fairer alternative to enforcing a strict age limit of 18 years for reimbursement of a second cochlear implant.

Paper title:

Reimbursement Policy Decisions for Bilateral Cochlear Implantation in Adults: How Should They Be Evaluated?

Authors:

Wendy J. Huinck¹, Simone Naber², Stef Groenewoud^{2, 3}, and Adriana L. Smit^{4, 5}

¹Department of Otorhinolaryngology, Radboud university medical center, Nijmegen, The Netherlands. Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands

² IQ Health, Radboud university medical center, Nijmegen, Netherlands

³ Theological University Utrecht, Utrecht, The Netherlands

⁴Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

⁵ University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands

Competing interests: None to declare

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