Cochlear Implant denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a surgical cochlear implant. Findings: The physician reviewer found that Cochlear implants have traditionally been used to treat bilateral sensorineural hearing loss in the presence of normal cochlear anatomy when conventional amplification techniques do not provide adequate hearing rehabilitation. However, the benefits of treating unilateral hearing loss (UHL) and single-sided deafness (SSD) with cochlear implants have been established in recent medical literature. Patients with UHL/SSD experience difficulty with speech comprehension in both quiet and competing noise environments, sound localization, and severe ipsilateral tinnitus.

The patient is a five-year-old male born with profound bilateral sensorineural hearing loss. He underwent cochlear implantation to his right ear at the age of 24 months. Testing at this time reveals that he receives no benefit from wearing a hearing aid on the non-implanted ear and the parents wish to have an cochlear implant placed for the right ear. Their request for authorization of the sequential cochlear implant was denied by the Health Plan as not medically necessary.The science of cochlear implantation is changing rapidly with time. The criteria for implantation has progressed so that children are benefiting from implantation at a younger age than was initially thought appropriate. There have been several studies exploring the benefit of wearing hearing amplification (external aid) on the unimplanted ear for patients with unilateral implants.

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 cochlear implants. Findings: Three physician reviewers found that cochlear implantation is a recognized technology to improve patient’s perception of sound after development of hearing loss or, in the pediatric population, of establishment of hearing perception in children who were born with congenital hearing loss. However, the use of this technology is beneficial in patients with bilateral hearing loss to allow the patient a perception of hearing. While its use in patients with single sided deafness is growing, there are few randomized controlled studies in the literature to establish substantial outcomes of their utilization.

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