Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old male with profound bilateral sensorineural hearing loss, 110dB right, 105dB left. There is no family history of hearing loss. Cochlear anatomy appears normal on temporal bone CT. The patient has worn bilateral hearing aids since 18 months of age and a frequency modulated system at school, which have improved his hearing threshold to moderately severe range, assisting primarily in sound localization. The patient, supported by both parents, wishes to proceed with cochlear implantation since behind the ear aids are of no benefit now and the patient has not been using them recently due to the absence of benefit noted with use.The patient is very motivated and desires to be independent. He is mainstreamed in high school and maintains a high grade point average in addition to being involved in extracurricular activities. He interacts well with normal hearing peers and has strong family support. Both the patient and his parents demonstrate very realistic expectations regarding benefits and limitations to cochlear implantation. The patient has excellent lip reading skills and high-level language skills, both expressive and receptive. ASL is his primary communication mode, but he continues to practice speech reading and utilizes his voice daily to communicate with his many hearing friends.The patient was evaluated for cochlear implant candidacy and was determined to be an appropriate candidate for cochlear implantation in his left ear. The Health Plan indicates the requested procedure is not medically necessary.Cochlear implant candidacy continues to expand. When cochlear implants were first approved by the FDA in 1985, the device was for postlingually deaf adults with no benefits from hearing aids and hearing loss greater than 100dB. Since then criteria has been extended to include children 12 months of age and above and audiologic criteria continues to expand, now to include children and adults with prelingual long-term deafness.Many factors affect the auditory performance of cochlear implant recipients. These include age of onset of deafness, age at implantation, duration of deafness, degree of residual hearing, electrophysiological factors, and individual device factors in addition to psychological and social factors. Individual auditory performance varies immensely despite similar prognostic indicators.Most studies agree that postlingually deaf adults with the shortest duration of deafness tend to achieve the highest speech perception scores. Adults with prelingual long-term deafness who receive cochlear implants typically do not develop open set speech recognition, although they do recognize environmental sounds and many develop enhanced speech-reading abilities. Congenital or prelingually deaf children appear to experience the greatest benefit when implanted prior to age two. However, because of wide individual variability in each age group, more recent studies indicate that older children (greater than 12 years old) should not be excluded from implantation based on age.Studies published after 2001 reveal substantial improvement in speech perception in patients with long-term deafness. Current encoding systems have more advanced strategies that seem to enhance performance. This includes obtaining considerable open set speech understanding after implantation. Most updated studies support expanding implant criteria to the congenitally long-term deafened population, including prelingually deaf adults and children.An important success factor for cochlear implants in prelingually deaf adults include history of having used the auditory channel with amplification for a period of their lives as well as being comfortable with spoken language. This patient has maintained use of auditory input (hearing aids) throughout the majority of his life. Although his primary communication mode is ASL, he continues verbal communication efforts and speech reading. Furthermore, the patient and his family have realistic expectations and are highly motivated. Given these factors, cochlear implantation is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.