Auditory Processing Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) auditory processing disorder therapy sessions, one-on-one with an audiologist once a week for 12 weeks and (2) auditory processing disorder therapy sessions utilizing Buffalo Model Auditory training. The ability to detect and interpret external sound stimuli is accomplished through the coordinated efforts of the peripheral hearing organs and the central auditory processing center. The peripheral hearing organs include the auricle, external auditory canal, tympanic membrane, middle ear, and cochlea, which together translate physical acoustic sound waves into neural signals.

The parent of a 10-year-old female enrollee has requested speech therapy for the treatment of the enrollee’s auditory processing disorder and dyslexia. Findings: The physician reviewer found that speech and language therapy is medically necessary for treatment of this patient’s auditory processing deficits. The American Speech-Language-Hearing Association (ASHA) broadly defines central auditory processing as the “efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information.” Auditory processing includes the following: sound localization and lateralization, auditory discrimination, auditory pattern recognition, temporal aspects of audition including temporal integration, temporal discrimination, temporal ordering and temporal masking, auditory performance in competing acoustic signals, and auditory performance with degraded acoustic signals.

Where the denial was upheld

Findings: The physician reviewer found that the patient’s parent has requested authorization and coverage for Central Auditory Processing Disorder Therapy (CAPDOTS)-Integrated (adolescent version) listening program and/or Safe and Sound Protocol hearing therapies. The submitted documentation does not support the medical necessity of the requested services. The records indicate that the patient has been diagnosed with autism spectrum disorder (ASD) and has a history of auditory processing disorder, attention deficit hyperactivity disorder (ADHD), combined presentation, bilateral hyperacusis, tinnitus, misophonia, and visual processing disorder. The records show that the patient underwent an auditory processing evaluation, which found that the patient’s hearing sensitivity for pure tones was in the normal range in both ears, with many thresholds below 0-decibel hearing level (dBHL).

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a Diagnostic Audiologic & (Central) Auditory Processing Evaluation. Findings: The physician reviewer found that Auditory processing disorder (APD) is a well-recognized condition. The condition is associated with reading, language, and reading disorders. It is also associated with other conditions such as attention deficit hyperactivity disorder (ADHD), developmental language disorders, and reading disorders (Bailey, T.). Abnormal auditory testing results seen in children diagnosed with central auditory processing disorder (CAPD) are most commonly due to attentional problems (Moore, D., et al.).

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for auditory processing disorder was denied, the published record says the denial is worth fighting.