Hearing Loss denials in California external review

What the reviewers wrote

Where the denial was overturned

A 64-year-old male enrollee has requested surgical implantation of a bone anchored hearing aid (BAHA) for treatment of his hearing loss. Findings: The physician reviewer found that the BAHA is indicated for use in patients with hearing loss who cannot tolerate the use of a conventional amplification device. In the past, this was often interpreted to mean patients with external or middle ear disease that precluded the use of traditional hearing aids. Over the years, the use of this device has been expanded to include patients with severe unilateral sensorineural hearing loss. It has been found that there is a reduction in head-shadow effect and enhancement of speech recognition with the use of a device that routes sounds from a hearing impaired ear to a contralateral normal or lesser impaired ear. Both the BAHA and the contralateral-routing of signal (CROS) hearing aid accomplish this.

The parent of a 12-year-old female enrollee has requested a cochlear implant external processor replacement for treatment of her hearing loss. Findings: The physician reviewer found that the cochlear implant is useless unless there is a functional external processor that can be appropriately adjusted. The patient’s current processor outlived its usefulness. It was medically appropriate and indicated to replace that device. There was no alternative available for the patient and the processor at issue was integral to her hearing and was indicated.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan, positron emission tomography (PET) scan, biopsy and pathology for evaluation of the enrollee’s neck pain, hearing loss, rhinitis, and nasal polyp. Findings: The physician reviewer found that the medical literature, PET/CT imaging can have a substantial impact on intended management when used for three targeted diagnostic indications: (1) determining whether a suspicious lesion is cancer; (2) detecting an unknown primary tumor site in a patient with confirmed or strongly suspected metastatic disease; and (3) detecting a primary tumor site in a patient with a presumed paraneoplastic syndrome. PET/CT plays a crucial role in the diagnosis and management of patients with head and neck squamous cell cancer (HNSCC).

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a right ear hearing aid. There is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In a study to assess the long-term effectiveness of interventions to promote the use of hearing aids, Barker and colleagues found that “There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term.” In this case, the patient has normal hearing in her right ear, with a speech reception threshold of 10 dB, indicating that she can hear 50% of the words at a 10 dB level, which is quieter than a whisper, and 100% word discrimination at conversational speech levels.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hearing loss, then check the rights and deadlines that apply to your plan.