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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for audiology services to evaluate and test for central auditory processing disorder (CAPD). The requested services, in this case, represent a comprehensive hearing and language evaluation, specifically aimed at ruling out CAPD. The ability to hear and perceive sounds, broadly speaking, is the responsibility of the peripheral hearing organs and central auditory processing center. The peripheral hearing organs include the auricle, ear canal, tympanic membrane (TM) middle ear space, and the cochlea. The organs essentially encode physical acoustic sound waves into neural signals and the signals are then transmitted, via the cochlear nerve, to the central auditory processing center in the brain.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for audiology services to evaluate for central auditory processing disorder (including: Evoked otoacoustic emissions, limited; Comprehensive audiometry threshold evaluation and speech recognition; Tympanometry and Acoustic Reflex Testing; Evaluation of central auditory function, with report initial 60 minutes; and Evaluation of central auditory function, additional 15 minutes). The records provided for review include a history of seizure disorder with multifocal brain lesions, positive anti-nuclear antibody (ANA), and polyarthralgia, with concern for central auditory processing disorder (CAPD) and primary angiitis of the central nervous system (PACNS).

Where the denial was upheld

Findings: The physician reviewer found that the patient’s parent has requested authorization and coverage for auditory processing disorder testing to include: (1) evaluation of central auditory function, with report initial 60 minutes, (2) evaluation of central auditory function, additional 15 minutes, (3) comprehensive audiometry threshold evaluation and speech recognition, (4) evoked otoacoustic emissions, limited, and (5) tympanometry and acoustic reflex testing. Testing patients with diagnoses that affect cognition, such as attention deficit hyperactivity disorder (ADHD), can affect the results of a central auditory processing disorder (CAPD) evaluation or render it invalid. Without complete treatment for ADHD, including physician-recommended medication therapy, it is likely that the untreated symptoms of ADHD for this patient would impact the reliability of a CAPD evaluation.

The patient is a nine-year-old male who had difficulty learning to read during first grade. He was diagnosed as having a central auditory processing delay by a speech therapist. The patient has received speech therapy since March 2002. The patient’s speech therapist documented delays in auditory memory, interpretation and processing. A request has been made for authorization and coverage for speech therapy. The Health Plan indicates that speech therapy is not medically necessary for treatment of the patient’s clinical condition.Though central auditory processing disorder has been described in the medical literature, the neuropsychologic nature of the disorder is still ill defined and the true nature of the disorder remains unclear. As a result, appropriate treatment has not been well established and no techniques have been validated.

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 central auditory processing disorder was denied, the published record says the denial is worth fighting.