Hearing Problem denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 15-year-old male with profound bilateral sensorineural hearing loss, 110dB right, 105dB left. There is no family history of hearing loss. Cochlear anatomy appears normal on temporal bone CT. The patient has worn bilateral hearing aids since 18 months of age and a frequency modulated system at school, which have improved his hearing threshold to moderately severe range, assisting primarily in sound localization. The patient, supported by both parents, wishes to proceed with cochlear implantation since behind the ear aids are of no benefit now and the patient has not been using them recently due to the absence of benefit noted with use.The patient is very motivated and desires to be independent. He is mainstreamed in high school and maintains a high grade point average in addition to being involved in extracurricular activities.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear auditory implant for treatment of the enrollee’s hearing loss. Findings: The physician reviewer found that bone conduction hearing aids have been traditionally used for conductive hearing losses. However, expanded indications for Bone Anchored Hearing Aid (BAHA) implantations are developing for sensorineural hearing loss as well. Single-sided deafness (SSD) from pathology, such as acoustic neuromas, or sudden sensorineural hearing loss are recent rationales made for bone conduction aids. Reported benefits for SSD patients include better sound localization and better sound clarity. Classic thinking has been that bone stimulates both cochlea simultaneously.

Where the denial was upheld

This patient is a 32-year-old woman who during evaluation for problems with balance and complaints of aural fullness bilaterally, was found to have a mild sensorineural hearing loss involving the left ear. She was initially given the diagnosis of probable Meniere’s disease and treated with a diuretic. In May 2003, the patient had a worsening of her hearing on the left and was treated with steroids. She then developed tinnitus involving her right ear. Further evaluation included an MRI, which revealed the presence of a 1-2mm focus of enhancement at the superior posterior aspect of the right internal auditory canal. The patient consulted another provider for a second opinion and was diagnosed with right-sided acoustic neuroma.

The patient is a two-year-old female who has a history of profound bilateral congenital sensorineural hearing loss diagnosed at 15 months of age by Auditory Brainstem Response testing. A three-month trial of power hearing aids was of little benefit. Audiologic testing revealed responses/threshold between 100dB and no response for the right ear and between 95dB and no response for the left ear. Binaural aided testing with the power hearing aids revealed thresholds between 50-70dB. CT scan imaging of the temporal bones revealed anatomy suitable for cochlear implantation. The recommendation of the cochlear implant team is for simultaneous bilateral implants.

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 problem, then check the rights and deadlines that apply to your plan.