Classification of Follow-up Rehabilitation (“AHB”) in the Context of Postoperative Cochlear Implant (CI) Care

Abstract

This statement paper, prepared on behalf of the Presidential Board of the German Society of Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC), addresses the classification of postoperative follow-up care after cochlear implantation (“CI rehabilitation”). In September 2024, “follow-up rehabilitation (AHB)” after cochlear implant surgery was included in the indication catalog of the Deutsche Rentenversicherung Bund (DRV Bund). Based on the guideline of the Association of the Scientific Medical Societies in Germany (AWMF) (017–071) and the CI White Paper, the following assessment examines how the AHB is to be integrated within the overall care pathway. At present, the AHB procedure is applied exclusively in adults. The analysis demonstrates that the AHB represents a complementary element within basic therapy and follow-up therapy but does not replace them. A mandatory prerequisite for AHB is the early fitting of the audio processor, according to medical indication, within the first days after cochlear implantation. This alone ensures that the AHB can begin within the required 14 days after discharge from inpatient treatment. At the same time, it must be emphasized that an AHB as the sole measure would deprive patients of essential components of follow-up therapy. Accordingly, AHB is to be regarded as a structured supplement to established treatment pathways, but not as the exclusive format of postoperative care for CI patients.

Keywords

Cochlear Implant - Rehabilitation - AHB - Basic Therapy - Follow-up Therapy - Aftercare - Quality Control - Clinical Practice Guideline

Schlüsselworte

Cochlea-Implantat - Rehabilitation - AHB - Basistherapie - Folgetherapie - Nachsorge - Qualitätssicherung - Leitlinie

This article is available in German and English.
The terms used in this article are not gender-specific and explicitly apply to all genders.

1. Introduction

Postoperative care after cochlear implantation (CI) is a complex, multi-stage process that significantly contributes to the overall success of CI therapy. In addition to careful indication and surgical implantation, structured follow-up care is of central importance for hearing outcomes, quality of life, and social participation of CI recipients. According to the current AWMF guideline [1] and the CI White Paper [2], this care includes basic therapy, follow-up therapy, and lifelong aftercare.

In social law – particularly under SGB IX – “rehabilitation” refers to measures aimed at preventing health impairments, eliminating or reducing existing limitations, or compensating for their consequences, thereby restoring or securing participation in social life. Based on this definition, the term “rehabilitation” was already integrated into the revised 2020 AWMF guideline and the CI White Paper. It encompassed different models for practical implementation, such as outpatient, inpatient, day-care, or blockwise follow-up within the framework of basic and follow-up therapy. However, the legal status, contractual framework, and responsibility of the respective payers remain highly diverse.

With the inclusion of “CI rehabilitation” in the catalog of follow-up rehabilitation procedures – commonly referred to as “follow-up treatment (AHB)” – by the Deutsche Rentenversicherung (DRV) in September 2024 [3], a uniform, nationwide social law framework was created for the first time to provide defined components of basic and follow-up therapy as AHB. For patients, this provides a legally secure path to access defined postoperative rehabilitation measures after CI surgery.

However, the introduction of CI-AHB has also led to misinterpretations: some payers equate AHB with complete postoperative follow-up, treating it as a replacement for established aftercare models or as the sole form of basic and follow-up therapy. This view is inconsistent with both the content and the formal definitions in the AWMF guideline 017–071 and the CI White Paper, and it threatens the quality of CI care.

The aim of this statement paper, developed on behalf of the Presidential Board of the DGHNO-KHC, is therefore to correctly classify the role of AHB within the CI care pathway as defined by the AWMF guideline and the CI White Paper [1] [2]. In addition, terminology will be clarified, scientific evidence reviewed, and recommendations formulated to ensure guideline-compliant care and outcome quality.

2. The Postoperative CI Care Process

The AWMF guideline 017–071 and the CI White Paper of the DGHNO-KHC define postoperative care in three phases:

• Basic therapy: Begins immediately after surgery (a few days up to 6 weeks); includes activation and optimization of the audio processor (first fitting), initial audiological testing, first hearing and speech therapy measures, and medical check-ups.

• Follow-up therapy: Directly follows basic therapy and includes further comprehensive rehabilitation measures (outpatient, inpatient, day-care, blockwise), e. g., intensive hearing and speech therapy, audiological measures (e. g., fine-tuning of the processor), medical and technical check-ups. This phase may last several months or even years depending on individual conditions and outcomes. This applies to adults, but especially to children, for whom hearing and language development often only begins with CI implantation (“habilitation” rather than “rehabilitation”).

• Aftercare: Lifelong follow-up including technical checks, audiological controls, medical monitoring, evaluation of hearing and communication performance, and psychosocial participation. Depending on the outcome, renewed therapy needs may be identified, requiring another round of follow-up therapy.

The term “rehabilitation” is already integrated into the postoperative process of the current CI guideline and the CI White Paper. It encompasses parts of basic and follow-up therapy without fully covering them and is graphically represented as a “dashed line” within these therapy phases ([Fig. 1]). This makes it clear that rehabilitation constitutes only part of basic and follow-up therapy. After follow-up therapy, lifelong aftercare follows.

Fig. 1 Depiction of the care pathway with a cochlear implant [(Source: AWMF Guideline on Cochlear Implantation. Access on 09/21/2025 under: (Accessed September 21, 2025 at: https://register.awmf.org/de/leitlinien/detail/017-071)) [1] and (Source: CI White Paper on Cochlear Implantation in Germany. Access on 09/21/2025 under: (Accessed September 21, 2025 at: https://cdn.hno.org/media/2021/ci-weissbuch-20-inkl-anlagen-datenblocke-und-zeitpunkte-datenerhebung-mit-logo-05-05-21.pdf)) [2]]. The illustration covers the chronological phases of care (preoperative evaluation, surgery, basic therapy, follow-up therapy, aftercare), the content components (e. g., audiological therapy or hearing and speech therapy), as well as the delegable (white fields) and non-delegable (gray fields) tasks of the CI-providing institution. Parts of basic and follow-up therapy can be delivered as rehabilitation measures (dashed line). Rehabilitation does not replace basic or follow-up therapy. Rather, a rehabilitation measure (or “follow-up rehabilitation, AHB”) presupposes prior basic therapy (processor fitting phase or early fitting in the case of AHB) and the continuation of follow-up therapy after the completion of the rehabilitation program. Thus, the rehabilitation measure (including AHB) supplements existing basic and follow-up therapy concepts but by no means replaces them. [rerif]

3. Conceptual Definitions of Rehabilitation

In the context of CI care, the postoperative phase has primarily been described in the AWMF guideline using the terms basic therapy and follow-up therapy. These are followed by lifelong aftercare. While the aim of basic therapy is to initiate the CI system (first fitting phase), the goal of follow-up therapy is to ensure the “optimal use” of the CI for each individual patient. The AWMF guideline 017–071 (2020) describes these phases in detail, both in content and timing [1].

The term “rehabilitation” is used in different ways, as it is defined and applied differently in medical practice and in social law. In medical practice, it generally refers to measures intended to restore or improve functions after illness or medical intervention. In social law, the term serves to delineate entitlement and responsibilities for benefits (SGB V, VI, and IX). Thus, it is often associated with formal requirements regarding indication, timing, scope, and structural framework conditions.

Distinct from this is the designation “medical rehabilitation” as used in individual cases in accordance with § 40 SGB V and § 42 SGB IX. CI-providing institutions (CIVE) implement postoperative follow-up care through different models. Some institutions have concluded so-called “CI rehabilitation contracts” with payers on the basis of § 111 and § 111c SGB V. These contracts provide rehabilitation services under § 40(1) and (2) SGB V for insured patients of certain health insurance companies or state associations. Depending on the contractual conditions, these services may include different elements of basic and follow-up therapy, and in some cases also aftercare, for up to two years after CI surgery. For children, substantially longer periods apply due to their extended hearing and language development.

In contrast, rehabilitation for pension insurance institutions represents a central instrument primarily intended to maintain or restore the employability of insured persons – so that they can remain in working life as long as possible and not have to claim disability pensions prematurely. This form of rehabilitation is strictly regulated and very clearly defined with respect to the application process, eligible recipients, and accredited providers.

4. Follow-up Rehabilitation (AHB) and its Prerequisites

With the inclusion of CI care in the AHB indication catalog in 2024, a formal legal option was created to deliver parts of basic and follow-up therapy as a time-limited rehabilitation measure as defined by the pension insurance system [3]. A key prerequisite for this is the implementation of an “early fitting” of the audio processor, i. e., initiation of basic therapy within the first days after surgery. Only in this way is it possible to start this rehabilitation measure (AHB) within 14 days after hospital discharge. This is an essential formal requirement for conducting an AHB.

In addition, an AHB must be carried out either as an inpatient program or as a full-day outpatient measure. It is important to emphasize that AHB does not replace the entire postoperative care pathway; rather, it relocates certain components of basic and follow-up therapy to an earlier point in time. Whereas in many cases patients after CI surgery previously received approval for inpatient rehabilitation only after months or even years, CI-AHB now allows the start of this measure within two weeks after surgery. Thus, AHB does not change the content of rehabilitation, but only the timing of its initiation within the legal framework of follow-up rehabilitation. This applies especially to patients treated in CI-providing institutions, where the auditory and speech therapy components of basic and follow-up therapy (according to guidelines) were already implemented in collaboration with cooperating rehabilitation centers. Therefore, AHB does not constitute a new module of care, but merely an option for the earlier implementation of established therapeutic content.

5. Scientific Evidence for Early Fitting

A central criterion for conducting AHB after cochlear implantation is the so-called early fitting, meaning the expedited initial activation of the audio processor within a few days after surgery. Until recently, this was routinely performed about 4–6 weeks postoperatively. Early fitting provides the medical and technical foundation for meeting the key AHB requirement set by the German Pension Insurance, namely the initiation of rehabilitation within 14 days after hospital discharge.

The basic feasibility and safety of such early fitting were described as early as 2018 [4]. That study demonstrated that early CI activation – within just a few days after surgery – can usually be carried out without negative effects on healing or functional outcomes, provided there is careful patient selection and specific surgical conditions (e. g., minimally invasive approaches, minimal postoperative swelling).

These findings were further confirmed in a prospective long-term study [5] involving a large patient cohort with early processor activation, which examined long-term effects on speech understanding, audiometric outcomes, and complication rates. Even after one year, there was no disadvantage of early fitting compared to conventional activation four to six weeks post-surgery. On the contrary, advantages were documented regarding patients’ subjective assessments of earlier therapy initiation.

These insights formed the basis for a pilot study on structured early CI rehabilitation to test the feasibility of an AHB-like model in patients with early processor activation. In this study, more than 90 % of participants were able to begin inpatient rehabilitation within the formal AHB timeframe and achieved comparable therapeutic benefit [6]. This confirmed not only the evidence supporting early fitting but also its importance for systematic CI care. The study demonstrated that AHB is enabled by early fitting – it requires it – but does not replace the subsequent individualized follow-up therapy, which remains necessary according to the guideline.

It should also be emphasized that these studies were conducted exclusively in adults, meaning that no conclusions can currently be drawn about the applicability of AHB in children. Consequently, early and time-limited AHB is currently only applicable in adults.

6. Misinterpretations and Current Misunderstandings Among Payers

Since the inclusion of CI rehabilitation in the AHB catalog of the German Pension Insurance in 2024, reports from CI-providing clinics and rehabilitation centers have increasingly described problematic interpretations of AHB by some payers. It has been repeatedly reported that services of outpatient, inpatient, day-care, or blockwise CI follow-up therapy have been rejected or restricted with reference to the availability of AHB. This concerns both health insurance funds and pension insurance providers. In some cases, even when existing care contracts with health insurers are in place, patients have been redirected to the pension insurance as the supposedly responsible payer.

The mistaken assumption underlying this practice is: if an AHB is formally possible after CI treatment, then it must be applied and is fully sufficient as rehabilitation. However, this equation of AHB with CI follow-up therapy represents a professionally untenable simplification, which contradicts both the recommendations of the AWMF guideline and the CI White Paper as well as the realities of care.

According to the definition of the German Pension Insurance (DRV), AHB is a structured, time-limited measure whose particular feature is that – if prerequisites such as early fitting are fulfilled – it begins immediately or within a close temporal and contextual relationship to inpatient hospital treatment, and no later than 14 days after discharge. Its duration, however, is limited: typically three to five weeks of inpatient stay with a clearly defined therapy plan. Within this time, central measures of CI rehabilitation can be initiated, especially in terms of hearing and speech training as well as psychosocial stabilization. What AHB cannot fully provide, however, is the individually required longer-term audiological, medical, and speech-language therapeutic follow-up care up to the stage of aftercare – that is, the follow-up therapy in the true sense of the guideline.

The care of patients after completion of formal rehabilitation (i. e., AHB) is an integral part of follow-up therapy and thus clearly corresponds to the care pathway of the AWMF guideline and the CI White Paper. These explicitly state that further therapeutic measures of follow-up therapy must take place after rehabilitation (including AHB). The end of AHB therefore does not mark the transition to aftercare, but rather the continuation of follow-up therapy based on an individual medical-audiological assessment.

The current misinterpretation by some payers has even led to the rejection of applications for inpatient or outpatient follow-up therapy, individual hearing therapy, or technical aftercare after AHB. This results in gaps in care and a de facto disadvantage for affected patients compared to those who, prior to the introduction of AHB, received extended follow-up therapy. In the interest of equal treatment and evidence-based care, it is therefore urgently necessary that payers correct this misinterpretation.

7. Classification and Evaluation of AHB in the Care Pathway

AHB, as a new option within postoperative follow-up care after CI surgery, should generally be viewed positively. It offers patients the opportunity to access a structured inpatient or full-day outpatient rehabilitation program at an early stage and within a legally secure framework. The prerequisite is a successful early fitting, which must be performed at the CI-providing institution (CIVE). Thus, AHB represents a socio-medically anchored partial measure within the overall care pathway. However, its role must be correctly integrated into the pathway. The indication for AHB must also be determined individually, meaning that it will not be applicable to every patient (e. g., not in cases of postoperative wound swelling or pain).

According to the AWMF guideline 017–071 and the CI White Paper, rehabilitation – including AHB – is not defined as an independent or final measure, but rather as a component of basic and follow-up therapy (1) (2). The end of a time-limited rehabilitation measure (e. g., AHB) therefore does not represent the end of follow-up therapy and must not be misinterpreted as the automatic beginning of aftercare ([Fig. 1]). Furthermore, AHB itself is limited in duration and does not address all the needs of CI patients – particularly not in complex cases or in patients with special linguistic or social challenges.

Another relevant point concerns the structural availability of AHB: at present, there are very few rehabilitation centers in Germany with explicit authorization to provide AHB for CI patients. Therefore, nationwide coverage of approximately 5,000 CI patients per year through AHB alone is currently not feasible. This underscores the continuing importance of other established forms of care, such as outpatient, inpatient, day-care, or blockwise basic and follow-up therapy.

8. Conclusions

AHB is a valuable addition to the CI care process – particularly for those patients in whom early, structured rehabilitation is both sensible and feasible. However, it is not a mandatory measure and must under no circumstances be understood as a complete substitute for established models of basic and follow-up therapy, such as rehabilitation contracts with health insurance funds (e. g., contracts under § 111 and § 111c SGB in conjunction with § 40 (1) and (2) SGB V). Furthermore, the individual suitability of a patient for the AHB procedure must be determined by the CI-providing institution (CIVE), taking into account medical and audiological aspects as well as the patient’s preferences.

The AWMF guideline 017–071 and the CI White Paper clearly state that further therapeutic steps of follow-up therapy must take place after any time-limited rehabilitation measure (e. g., AHB). An exclusive reliance on AHB without subsequent, individualized follow-up care contradicts these recommendations and jeopardizes the quality of CI care.

9. Summary

• AHB has been studied only as an early and time-limited rehabilitation measure in adults and is therefore currently applicable only to adults.

• AHB can only be applied following individual indication by the CI-providing institution (CIVE); not all patients are suitable for AHB.

• AHB is a complementary, but not mandatory, model of care within basic and follow-up therapy.

• Implementation of AHB requires an early fitting that is both medically indicated and organizationally feasible.

• Even after AHB, there remains, according to the CI guideline and the CI White Paper, both an entitlement and a medical necessity for further follow-up therapy.

• Exclusive reliance on AHB would mean that patients are denied essential parts of follow-up therapy—representing a deterioration compared to previous models of care.

• Established pathways of care, such as outpatient, inpatient, day-care, or blockwise therapies, remain indispensable and must be fully preserved.

• Nationwide provision through AHB alone is currently not feasible due to capacity limits—existing therapy facilities therefore continue to require secure funding and a legally sound framework.

• Payers and self-governing bodies are called upon to correctly classify AHB and not to mistakenly equate it with comprehensive CI basic or follow-up therapy.

Note

Language editing of this statement was supported by an AI system (ChatGPTplus, OpenAI). Full responsibility for content, structure, and conclusions lies entirely with the authors.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 AWMF S2k-Leitlinie Cochlea-Implantat-Versorgung. Registernummer 017–071. Version 2020. Accessed September 12, 2025 at: https://register.awmf.org/de/leitlinien/detail/017-071
• 2 Weißbuch Cochlea-Implantat-Versorgung in Deutschland. 2. Auflage. DGHNO-KHC, 2021. Accessed September 12, 2025 at: https://cdn.hno.org/media/2021/ci-weissbuch-20-inkl-anlagen-datenblocke-und-zeitpunkte-datenerhebung-mit-logo-05-05-21.pdf
• 3 Accessed August 07, 2025 at: https://www.deutsche-rentenversicherung.de/SharedDocs/Downloads/DE/Experten/infos_fuer_aerzte/ahb_indikationskatalog.html
• 4 Günther S, Baumann U, Stöver T. Early Fitting in Cochlear Implantation: Benefits and Limits. Otol Neurotol 2018; 39 (04) e250-e256
• 5 Bruschke S, Baumann U, Stöver T. Long-Term Follow-Up of Early Cochlear Implant Device Activation. Audiol Neurootol 2021; 26 (05) 327-337
• 6 Bruschke S, Zeh R, Baumann U. et al. Die Aufnahme einer Rehabilitationsmaßnahme in den Katalog der Anschlussrehabilitation. Laryngo-Rhino-Otol 2025; 104: 304-310

Publication History

Article published online:
02 October 2025