Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss
Treatment: Durable medical equipment - cochlear implant
The insurer denied coverage for durable medical equipment - cochlear implant.
The denial is overturned.

This case involves a young child diagnosed with sensorineural hearing loss of the left ear with unrestricted hearing of the right ear. The patient was found to have normal hearing with flat tympanometry in the right ear and at least severe mixed hearing loss in the left ear with normal tympanometry and absent emissions suggesting that the hearing loss was cochlear in nature. Magnetic resonance imaging (MRIs) were obtained showing normal contrast-enhanced MRI of the auditory canals and the brain. The patient received a notice of adverse determination, which stated that the patient had profound hearing loss in the left ear but normal hearing in the right ear. The treating physician wanted to place a cochlear implant in the left ear. The clinical summary, benefit plan, and policy were reviewed by an ear, nose, and throat doctor. The policy indicates that a cochlear implant is approved only when there is severe hearing loss in both ears. The treating physician responded stating that the patient was sent to the practice for evaluation of the left-sided severe to profound sensorineural hearing loss with essentially normal hearing in the right ear, what is commonly referred to as a single-sided deafness situation. The physician also noted the patient has Waardenburg syndrome, which puts her at increased risk for future hearing loss in her only hearing ear. The patient completed extensive audiologic evaluations including a hearing aid trial, which provided no benefit. The physician noted that the patient had a well-visualized and unremarkable nerve present to the left cochlea on MRI with no inner ear anomalies noted. Based on the physical and audiologic findings, the patient is an ideal candidate for a cochlear implant in the left ear. The physician went on to state that a cochlear implant is the only option for single-sided deafness that can potentially provide speech perception improvement to the left ear. Without a cochlear implant, the patient is unable to localize sound, which causes increased work of hearing with the good ear and causes great difficulty discerning voices in loud or crowded places. The physician endorsed that there is a growing body of evidence confirming the positive and long-lasting impact of cochlear implant in patients with single-sided deafness including sound localization, tinnitus suppression, significantly improving speech discrimination in difficult listening environments, and overall improvement in quality of life.

Current medical literature has found that pediatric subjects with single-sided deafness benefit substantially from cochlear implantation (CI). Objective speech outcome measures are improved in both quiet and noise, and bimodal speech reception thresholds and noise are greatly improved. Significant CI benefits were observed for tinnitus severity, localization, speech understanding, and Quality of Life (QoL). While the current policy has claimed that the patient must have bilateral hearing loss to receive approval for cochlear implants, given that there is substantial evidence noting that cochlear implants can be of significant benefit to those individuals with single-sided deafness, not only in reducing tinnitus, but improving their threshold for hearing, improving their speech, and leading a better quality of life in general. The evidence provided for review has confirmed that she is an ideal candidate for use of a cochlear implant given that she has severe hearing loss in the left ear that is amenable to treatment with a cochlear implant.

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 durable medical equipment - cochlear implant is substantiated.