Sensorineural Hearing Loss: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary:The parent of a one-year-old male enrollee has requested authorization and coverage for an OtoSCOPE hearing loss genetic testing panel. The International Pediatric Otolaryngology Group (IPOG) consensus recommendations for the workup of hearing loss in pediatric patients reported that in the setting of SNHL, comprehensive genetic testing is an appropriate next step following physical examination and audiogram. Researchers found in a study of 1,119 patients that comprehensive clinical genetic testing with targeted genomic enrichment and massively parallel sequencing identified an underlying genetic cause for hearing loss in 39% of patients. Researchers identified an overall diagnostic rate of 41% with hearing loss genetic panels using massively parallel sequencing.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen treatment. Many guidelines for hyperbaric oxygen treatment and hearing loss have not been updated to reflect the current medical literature and routine practice of hyperbaric oxygen. Studies found that hyperbaric oxygen treatment and combined therapy offered some benefits in hearing improvement. Combined intratympanic steroids and hyperbaric oxygen treatment may result in recovery of hearing, especially in lower frequencies. Hyperbaric oxygen treatment plus existing conventional treatment has also been associated with a better outcome than conventional treatment alone. Hyperbaric oxygen treatment is a safe and beneficial adjuvant therapy for sensorineural hearing loss patients.

Where the denial was upheld

An enrollee has requested hyperbaric oxygen (HBO) therapy. The submitted documentation does not support the medical necessity of the requested services. The patient has had long-standing progressive hearing loss and tinnitus. The evidence for HBO therapy has been limited to small case series from Europe and Asia, with very little evidence from well-controlled studies in the United States. The evidence for HBO therapy is based on its possible effect on sensorineural hearing loss, as referenced by colleagues. However, this evidence points to the necessity of very early (less than 14 days from onset of hearing loss or tinnitus) intervention with hyperbaric oxygen, as noted by colleagues. In this case, HBO therapy has been requested years after the patient’s CVA and would be undertaken months after the patient’s audiogram.

A 44-year-old female has requested hearing aids for treatment of mild to severe sensorineural hearing loss. Findings: The physician reviewer found that based on the results of the hearing evaluation performed, the patient was diagnosed with sensorineural hearing loss in the high frequencies. However, the patient’s speech reception threshold was found to be within normal limits at 20 dB in the right ear, 25 dB in the left ear, with excellent discrimination scores at 86% in the right ear, 90% in the left ear. In these clinical circumstances, the patient does not meet medical necessity criteria for use of hearing aids for this specific type of hearing impairment. Most of the patient’s hearing loss is in the high frequencies above the speech range of 2000 Hz. Standard occupational noise exposure may induce hearing impairment.

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 sensorineural hearing loss was denied, the published record says the denial is worth fighting.