Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 49-year-old female with a history of progressive asymmetric sensorineural hearing 
loss (ASNHL) seeking approval for a right-sided cochlear implant (CI). The patient was first 
diagnosed with hearing loss in 2014 and started wearing conventional hearing aids in 2015. The 
Health Insurer has denied the requested services as not medically necessary for treatment of the 
patients medical condition. This denial is the subject of this appeal and determination. 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. Needle electromyography 
and  continuous  intraoperative  neurophysiology  monitoring  of  the  right  ear  are  both  to  be 
performed along with the right CI in order to decrease risk of injury to the seventh cranial nerve. 
These techniques are an adjunct to the CI placement procedure and are required to safely implant 
the device. The benefits of treating unilateral hearing loss (UHL) and single-sided deafness (SSD) 
with cochlear implants have been established in recent medical literature (Zeitler and Dorman). 
Patients with UHL/SSD experience difficulty with speech comprehension in both quiet and 
competing noise environments, sound localization, and severe ipsilateral tinnitus. In a study 
investigating the effects of CI on sound localization and speech comprehension in competing noise 
environments in patients with UHL/SSD. Zeitler and colleagues found that speech comprehension 
and sound localization improved significantly, with some patients achieving localization in the 
95th percentile of normal hearing patients. A second study by Zeitler and colleagues demonstrated 
that CI provided significant improvement in tinnitus in young patients with SSD. In 2019, the U.S. 
Food and Drug Administration (FDA) approved unilateral CI placement in patients five years of 
age and older. Finally, in 2022, the American Cochlear Implant Task Force determined that CI is 
an effective treatment option for patients with unilateral hearing loss and single sided deafness. 
The FDAs specific criteria for the requested Cochlear Nucleus 7 indicates that it is recommended 
for  adults  with  moderate  to  profound  sensorineural  hearing  loss  and  limited  benefit  from 
conventional amplification defined as preoperative word (sentence) comprehension less than or 
equal to 50% in the ear to be implanted and less than or equal to 60% in the opposite ear. The 
patient continued to experience hearing difficulties despite the use of hearing aids. A hearing test 
performed on 8/10/22 demonstrated a significant decline in her word comprehension in the right 
ear. A review of the record indicates word recognition scores of 12% on the right ear, 44% on the 
left ear and 24% binaurally.  Therefore, the requested  cochlear device, implantation, needle 
electromyography, and continuous intraoperative neurophysiology monitoring in the right ear are 
medically necessary for treatment of the patient.