Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sensorineural hearing loss. 

Treatment: Cochlear implant and implantation. 

The insurer denied coverage for cochlear implant and implantation. 

The denial is overturned. 

This is a female patient who was diagnosed with severe to profound permanent sensorineural hearing loss of the right ear that has not responded to the use of a hearing aid. The patient experiences persistent bothersome tinnitus of the right ear interfering with her ability to concentrate and sleep. Since losing hearing in the right ear, the patient has continued to rely on her left ear for communication. The patient has completed extensive cochlear implant evaluations and was deemed to be an appropriate candidate for right cochlear implantation. The patient's physician states that the patient's case has been denied on the basis of single-sided deafness, but the patient's unique situation does not allow an identifiable cause of hearing fluctuation; therefore, it has been strongly advocated that the patient be approved for cochlear implantation as soon as possible so that she can begin the process of auditory rehabilitation. The recommendation has been made for cochlear implant and implantation. 

A cochlear implant is a device that can be used to improve hearing in people with a specific form of hearing loss known as sensorineural hearing loss (when sound cannot be properly transmitted from the inner ear to the hearing portion of the brain). Cochlear implants are typically used for people who do not benefit from a hearing aid or other assistive listening devices because of the severity of their hearing loss. Unlike hearing aids, which increase the volume of sound and deliver it to the ear, cochlear implants bypass the area of the inner ear that is not functioning correctly (called the cochlea), and directly stimulate the nervous structures of the inner ear. 

As per literature review, single-sided deafness and asymmetric hearing loss have been proposed as an indication for cochlear implantation. Most options considered rely on the transfer of sound from the poor ear to the better ear, using Contralateral Routing of the Signal (CROS) hearing aids or bone anchored hearing aids (BAHA). In contrast, cochlear implantation allows the poor ear to be stimulated and binaural hearing abilities to be at least partially restored. There are many level IV published studies that have reported an improvement in the spatial localization of incoming sound and better speech recognition in noisy environments after cochlear implantation in patients with unilateral deafness. It also provides consistent relief of tinnitus in many patients. In addition, the Food and Drug Administration (FDA) has now approved cochlear implantation as a treatment for single-sided deafness. 

Based on the review of the medical records and literature, this patient meets criteria for cochlear implantation for single-sided deafness. The implant will help improve the patient's communication skills and may also improve her tinnitus. Thus, cochlear implant and implantation is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for cochlear implant and implantation is substantiated. The insurer's denial should be overturned.