Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ear Nose and Throat. 
Treatment: Cochlear Implants. 
The insurer denied cochlear implant. 
The denial is overturned in whole.

The patient is a male who developed a profound sudden right sensorineural hearing loss with poor word recognition and tinnitus. This affected the patient socially and academically and he withdrew from school, undertaking home schooling. He was unsuccessfully treated medically with transtympanic dexamethasone infusions. His complaints include difficulty understanding speech in noise, and with the directionality of sound. A computed tomography (CT) of the temporal bones were normal, the right cochlea patent and normal in shape and form. Exam of the ears were unremarkable and hearing in the left ear was unimpaired. The patient underwent a one month trial with a contralateral routing of signals hearing aid system and a traditional Resound behind the ear hearing aid with limited benefit, causing interference and difficulty hearing in noise. AZ Bio sentence recognition and CNC word and phoneme testing results were poor to zero.
Implantation of a right cochlear implant was recommended and is the service under review for medical necessity.

The health plan's determination is overturned in whole.

Implantation of a right cochlear implant is medically necessary for treatment of single sided deafness as it is appropriate in these clinical circumstances for this patient. 
Zeitler (2019) stated that single sided deafness can have severe and detrimental effects on multiple aspects of life including music appreciation, speech understanding in noise, speech and language acquisition, performance in the classroom and/or the workplace, and quality of life. Additionally, the loss of binaural hearing in single sided deafness patients affects those processes that rely on two functional ears including sound localization, binaural squelch and summation, and the head shadow effect. In a cohort study by Mertens implanted patients with single sided deafness over 36 months binaural effects were found to be significant. In single sided deafness group spatial release from masking and the head shadow, the two most robust binaural effects, were significantly present, and speech in noise results was significantly worse in the condition with a bone conduction device. In a 12 month cohort study by Dillon, significant subjective benefit was reported as early as the 1-month interval, indicating better performance with the cochlear implant compared with the preferred preoperative condition. Aided word recognition with the cochlear implant alone was significantly improved at the 1-month interval compared with preoperative performance with a hearing aid and continued to improve through the 12-month interval. The authors found that subjects demonstrated early, significant improvements in the bimodal condition on the spatial hearing tasks compared with baseline.
Many reports in the literature have demonstrated that cochlear implants are a reasonable, successful, and viable option for people with severe-to-profound unilateral hearing loss and is clinically appropriate for this patient and according to the evidence based literature, is medically necessary and improves patient outcomes.