Hearing Problem Loss denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for hyperbaric oxygen therapy services.Findings: Two of three physician reviewers found that the services at issue and requested services were, and are, likely to be more beneficial than any other available standard treatments for the patient’s medical condition.Hyperbaric oxygen therapy is thought to support the hypoxic tissue of the inner ear, reduce tissue edema and prevent reperfusing injury. Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines for sudden hearing loss state that clinicians may offer hyperbaric oxygen therapy combined with steroid therapy within two weeks of the onset of sudden sensorineural hearing loss (SSNHL).

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy service. Current medical literature supports the use of hyperbaric oxygen therapy for the treatment of idiopathic sudden sensorineural hearing loss. Researchers note that there is clinically meaningful improvement with the use of hyperbaric oxygen therapy in patients with moderate to profound idiopathic sudden sensorineural hearing loss that present for treatment within 14 days of the onset of symptoms. The authors further note that even patients presenting later than 14 days may show improvement with the use of hyperbaric oxygen therapy. The American Academy of Otolaryngology-Head and Neck Foundation indicates that hyperbaric oxygen therapy may be a viable consideration up to one month following symptom onset.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy. One source of medical literature has approved hyperbaric oxygen therapy for the treatment of patients with sudden hearing loss. However, another source of medical literature include salvage hyperbaric oxygen therapy plus steroids as treatment option for use within one month of symptom onset. The records provided for review document that this patient’s hearing loss has fluctuated with worsening hearing loss noted more than the recommendation for hyperbaric oxygen therapy. The patient’s condition was improved following treatment with steroid injections. The patient experienced onset of hearing loss. Subsequently, the patient reported a sudden worsening in their hearing.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for unilateral cochlear implant. The U.S. Food and Drug Administration (FDA) approved MED-EL’s cochlear implant for single-sided deafness (SSD) and asymmetric hearing loss (AHL) for patients five years of age and older in 2019. However, to fully meet criteria for cochlear implant for this indication, the FDA requires that “individuals with SSD or AHL must have at least one (1) month experience wearing a Contra Lateral Routing of Signal (CROS) hearing aid or other relevant device and not show any subjective benefit.” The documents submitted for review do not demonstrate that the patient used a CROS hearing aid, bone-anchored hearing aid (BAHA), or other relevant hearing aid for 1 month.

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