Single-sided Deafness denials in California external review
In the California DMHC record, independent physician reviewers decided 12 published external-review cases involving single-sided deafnessand overturned the plan’s denial in 50%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for single-sided deafness
| Category | Decisions | Overturned |
|---|---|---|
| Cochlear Implant | 6 | 33.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 44.4% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for left cochlear implantation surgery with or without mastoidectomy. Cochlear implants (CIs) have been used to treat sensorineural hearing loss for over 40 years. Traditionally, CIs have been utilized for bilateral hearing loss when conventional amplification techniques do not provide adequate hearing rehabilitation. The benefits of treating unilateral hearing loss (UHL) and single-sided deafness (SSD) with CI are well documented in the literature over the last two decades, leading to a paradigm shift in the treatment of UHL and SSD. Patients with UHL and SSD suffer specifically from difficulty with speech comprehension in both quiet and competing noise environments, sound localization, and severe ipsilateral tinnitus.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a cochlear implant device and a surgical implantation procedure. The benefits of treating single-sided deafness with cochlear implants have been documented in the literature, including improvements in word comprehension, sentence recognition, and tinnitus. Cochlear implant placement is U.S. Food and Drug Administration approved for appropriate candidates, including patients with single-sided deafness. Clinical guidelines support cochlear implantation in patients who have failed traditional non-surgical amplification.In this case, the patient has a history of right-sided deafness with severe tinnitus and has failed traditional non-surgical amplification.
Where the denial was upheld
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.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) hearing aids/molds for the left ear CROS system hearing aid for treatment of the enrollee’s bilateral sensorineural hearing loss. Findings: The physician reviewer found that a CROS hearing device is utilized for a patient’s hearing improvement when there is a sudden change of hearing unilaterally. The DME requested includes one device that serves as a microphone to pick up ambient sounds on one side of the head, and the other device serves to send the messages received into the good hearing ear by routing the signals received from one device to the other side. With this technology, the patient’s good ear can hear sounds from both sides of the head with improvement of hearing.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 single-sided deafness, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY