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

This patient is a 32-year-old woman who during evaluation for problems with balance and complaints of aural fullness bilaterally, was found to have a mild sensorineural hearing loss involving the left ear. She was initially given the diagnosis of probable Menieres disease and treated with a diuretic. In May 2003, the patient had a worsening of her hearing on the left and was treated with steroids. She then developed tinnitus involving her right ear. Further evaluation included an MRI, which revealed the presence of a 1-2mm focus of enhancement at the superior posterior aspect of the right internal auditory canal. The patient consulted another provider for a second opinion and was diagnosed with right-sided acoustic neuroma. This provider recommended the enrollee undergo a stacked auditory brainstem response audiometry test (ABR) and an ENG with infrared video testing of the posterior semicircular canal. Although the patients hearing loss is on the left, this patient has been unexpectedly found to have a small acoustic tumor on the right. It has been recommended that this tumor be removed. The natural history of the majority of these tumors is very slow growth. The complication rate with removal is less for smaller tumors. Because of this patients young age, it is not unreasonable that she undergo surgery for this problem. Also, because she has a hearing loss involved in the left ear, it is important that all efforts be made to preserve hearing in the right ear. However, a stacked ABR and infrared video ENG testing is not the current standard of care in this regard. Although multiple factors have been investigated towards the end of predicting hearing preservation in acoustic neuroma resection, none have been found to have absolute predictive value. Preoperative hearing loss, tumor size, speech description, ENG, and MRI have all been investigated. ABR has been used to detect the presence of retrocochlear pathology. Stacked ABR has been shown to predict retrocochlear pathology with greater sensitivity than routine ABR. However, since this patient has already had an MRI, her retrocochlear pathology (enhancement at the right IAC) is already known to be present, thus obviating the need for stacked ABR. Furthermore, the use of stacked ABR for predicting hearing preservation has not been proven to be useful and is not considered the standard of care at this time. Therefore, stacked ABR is not medically necessary for treatment of the patients acoustic neuroma.Additionally, although infrared video technology has been used extensively in ophthalmologic evaluation, the use of this technology with specific regard to posterior semicircular canal function and its relation to hearing preservation is not standard of care. Thus, infrared video technology for this indication is not in accordance with generally accepted professional standards and is not medically necessary for treatment of the patients condition.Regarding the patients request for surgical care with an out-of-network provider, there is no evidence that medically appropriate surgical care is not available in-network. The Health Plan indicates the credentials of the patients in-network provider include a fellowship in neurotology. Since there is a qualified surgeon available in-network, it is not medically necessary that the patient obtain care from an out-of-network provider. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.