IMPORTANCE: Cochlear implants enable improvements in speech perception, but music perception outcomes remain variable. Image-guided cochlear implant programming has emerged as a potential programming strategy for increasing the quality of spectral information delivered through the cochlear implant to improve outcomes. OBJECTIVES: To perform 2 experiments, the first of which modeled the variance in music perception scores as a function of electrode positioning factors, and the second of which evaluated image-guided cochlear implant programming as a strategy to improve music perception with a cochlear implant. DESIGN, SETTING, AND PARTICIPANTS: This single-center, prospective study recruited 50 adult patients with at least 6 months of cochlear implant listening experience and normal cochlear anatomy to participate in experiment 1 from 2013 to 2023. Data analysis was conducted from January to February 2024. Thirty-four of the 50 patients from experiment 1 also completed experiment 2. INTERVENTIONS: Cochlear implant programming using a computed tomography-guided electrode selection strategy. MAIN OUTCOMES AND MEASURES: University of Washington Clinical Assessment of Music score, including subtests of pitch discrimination thresholds, isochronous familiar melody recognition, and timbre recognition. RESULTS: Of 50 participants, 20 (40%) were female, and the mean (SD) age was 57.7 (16.4) years. Experiment 1 suggested that better music perception abilities in the 50 participants were associated with patients who were younger and had a postlingual onset of deafness, as well as electrode arrays with a full scala tympani insertion, higher modiolar distance, and shallower insertion depth. Experiment 2 suggested improvements in melody recognition in the 34 participants using the image-guided cochlear implant programming strategy. Patients with apical electrodes that were deactivated were more likely to demonstrate an improvement in their pitch perception thresholds with the image-guided strategy, likely due to the low-frequency stimuli used in the University of Washington Clinical Assessment of Music. CONCLUSIONS AND RELEVANCE: This study identified patient and device factors that were associated with music perception outcomes with a cochlear implant. These findings suggest that a personalized, image-guided approach to programming may improve music perception abilities for patients with cochlear implants.