Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deafness
Treatment: A surgery to insert a hearing device (procedure code 69930, cochlear implant)
The insurer denied coverage for a surgery to insert a hearing device (procedure code 69930, cochlear implant)
The denial is overturned

The patient is an adolescent who presented with hearing loss. The hearing is defined as profound within one ear. The patient has a history of failed hearing screening twice, one of which was a formal audiogram. Computed tomography showed a congenital aqueduct malformation within the right ear. A right-sided hearing aid was used without benefit. The recommendation was made for cochlear implantation to improve hearing and sound awareness. The request is to determine the medical necessity of said procedure.

According to Brown et al (2022), " Consonant-Vowel Nucleus-Consonant (CNC) word score perception in quiet significantly improved (1% to 50%, P &lt; .0001) by 12 months after activation. Speech perception in noise by Bamford-Kowal-Bench Speech-in-Noise Test (BKB-SIN) significantly improved in all three noise configurations; there was a 3.6 Decibels (dB) advantage in head shadow (P &lt; .0001), a 1.6 dB advantage in summation (P = .003), and a 2.5 dB advantage in squelch (P = .0001). Localization improved by 26 degrees at 9 months (P &lt; .0001). Speech, Spatial, and Qualities (SSQ) demonstrated significant improvements in speech (5.2 to 7.4, P = .0012), qualities of hearing (5.9 to 7.5, P = .0056), and spatial hearing (2.7 to 6.6, P &lt; .0001). SSQ subscales associated with binaural hearing were significantly improved, as was listening effort (P = .0082). Subjects demonstrated a non-significant improvement in fatigue."

According to Snapp et al (2020), "There is an increasing global recognition of the negative impact of hearing loss, and its association to many chronic health conditions. The deficits and disabilities associated with profound unilateral hearing loss, however, continue to be under-recognized and lack public awareness. Profound unilateral hearing loss significantly impairs spatial hearing abilities, which is reliant on the complex interaction of monaural and binaural hearing cues. Unilaterally deafened listeners lose access to critical binaural hearing cues. Consequently, this leads to a reduced ability to understand speech in competing noise and to localize sounds. The functional deficits of profound unilateral hearing loss have a substantial impact on socialization, learning and work productivity. In recognition of this, rehabilitative solutions such as the rerouting of signal and hearing implants are on the rise. This review focuses on the latest insights into the deficits of profound unilateral hearing impairment, and current treatment approaches."

According to Benchetrit et al (2021), "This systematic review and meta-analysis found that cochlear implantation for children with Single-Sided Deafness (SSD) was associated with clinically meaningful improvements in audiological and patient-reported outcomes; shorter duration of deafness may lead to better outcomes. These findings can guide future research efforts, refine cochlear implantation candidacy criteria, and aid in family counseling and shared decision-making."

Per Naik, A. N., Varadarajan, V. V., &amp; Malhotra, P. S. (2021), "The criteria and candidacy for pediatric cochlear implantation (CI) has significantly transformed over the past few decades and continues to evolve with technological advancements, and recognition of benefit in more diverse populations. Prolonged auditory deprivation among patients with profound sensorineural hearing loss has been shown to cause widespread degeneration in the central auditory system."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a surgery to insert a hearing device (procedure code 69930, cochlear implant) is substantiated.