Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

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 patients 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). The guidelines also state that clinicians may offer hyperbaric oxygen therapy combined with steroid therapy as salvage within one month of the onset of SSNHL. Under the guidelines, these are both valid treatment options for either initial treatment or salvage treatment. Researchers conducted a study which retrospectively reviewed clinical data for 334 patients with idiopathic sudden sensorineural hearing loss (ISSNHL) treated by hyperbaric oxygen therapy and intravenous steroids. The overall improvement rate was 69.2%, and they concluded that hyperbaric oxygen therapy appears to confer a significant additional therapeutic benefit when used in combination with steroid therapy for ISSNHL. If performed early, hyperbaric oxygen therapy may bring about hearing improvement in many patients who are unresponsive to initial therapy. Authors performed a retrospective cohort study involving a total of 300 patients and found that the proportion of patients responding to therapy and those with complete recovery was the highest in the group that combined treatment of hyperbaric oxygen in conjunction with intravenous steroid. In this case, the patient has a diagnosis of idiopathic sudden sensorineural hearing loss and received combined steroid therapy and hyperbaric oxygen therapy. The services at issue and requested services in this case are consistent with clinical practice guidelines and current medical literature. Accordingly, the hyperbaric oxygen therapy services in issue were likely to be more beneficial than any other available standard treatments for the patients medical condition. In addition, the requested hyperbaric oxygen therapy services are likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: Two of three reviewers determined that the services in issue and requested services were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.