Tinnitus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient requested authorization and coverage for hearing therapy (therapy services provided by a psychotherapist for the treatment of sound sensitivities (tinnitus, hyperacusis, and misophonia)) provided weekly for at least 24 sessions. Tinnitus is the perception of sounds in the absence of external acoustic stimulation. The pathophysiology of tinnitus is not fully understood and there is at present no “cure” for tinnitus that results in the tinnitus becoming inaudible. Hyperacusis is the intolerance of certain everyday sounds that cause significant distress and impairment in social, occupational, recreational, and other day-to-day activities. Misophonia is the abnormally strong emotional and behavioral reaction to these particular sounds or groups of sounds with a specific pattern and meaning to the patient.

The patient is a 56-year-old female who reports loss of hearing and tinnitus in her right ear since approximately August 2004. In addition, she has experienced dizziness, which appears to have since resolved, but the tinnitus is persisting and is constant. An MRI performed in 2004 revealed no evidence of an acoustic neuroma or other pathology in cerebellopontine angles. There was a small right frontal convexity meningioma noted. Based upon the information provided, it appears the patient has been seen by an ENT specialist and a hearing aid has been recommended.The patient has requested authorization and coverage for acupuncture.

Where the denial was upheld

The patient is a 43-year-old female with an almost two-year history of persistent tinnitus. The patient states the onset of this problem coincided with a severe flu she had in November 2003. The tinnitus began “as a small noise in the right ear” that occurred only when the enrollee lay on her right side. It has since become constant and is a swooshing noise most prominent with each heartbeat. The patient also has pressure around her ears and upper neck. In March 2004, an audiometric evaluation demonstrated the presence of bilateral mild to moderate high frequency hearing loss. In May 2004, an MRI was within normal limits. In November 2004, the patient was evaluated by another otolaryngologist. At that time hearing thresholds were found to be normal on the right with mild high frequency loss on the left. Tympanograms were slightly negative but within normal limits.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen chamber and oxygen concentrator for treatment of the enrollee’s tinnitus. Findings: The physician reviewer found that the request for hyperbaric oxygen chamber and oxygen concentrator are not medically necessary for treatment of the patient’s medical condition. The medical literature does not demonstrate any longstanding clinical benefit utilizing hyperbaric oxygen therapy for the treatment of subjective tinnitus. The data reports a modest degree of improvement of symptoms of sudden hearing loss when the treatment is initiated shortly after the development of the hearing loss. In this case, the patient’s trauma occurred more than one year ago.

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