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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for audiology services to evaluate for central auditory processing disorder (including: Evoked otoacoustic emissions, limited; Comprehensive audiometry threshold evaluation and speech recognition; Tympanometry and Acoustic Reflex Testing; Evaluation of central auditory function, with report initial 60 minutes; and Evaluation of central auditory function, additional 15 minutes). The records provided for review include a history of seizure disorder with multifocal brain lesions, positive anti-nuclear antibody (ANA), and polyarthralgia, with concern for central auditory processing disorder (CAPD) and primary angiitis of the central nervous system (PACNS). As noted in the medical literature, CAPD is a clinical diagnosis characterized by normal or near-normal hearing thresholds and a variety of audiologic symptoms such as memory difficulties and poor speech discrimination and localization. Central auditory processing tests are utilized in the work-up of patients when there is clinical suspicion of CAPD. Chowsilpa and colleagues noted that baseline audiological assessment, such as pure-tone audiometry and otoacoustic emissions, are important to control for the presence of peripheral auditory impairment during the work-up of patients for CAPD. PACNS is an inflammatory condition with variable, nonspecific symptoms such as headache, altered cognition, seizures, encephalopathy, and focal neurologic deficits that can affect cranial nerves (Beuker, et al.). A formal diagnosis of PACNS requires clinical findings of an acquired neurological deficit and angiographic or histopathological features of angiitis within the central nervous system, in addition to exclusion of other causes (Cho and Jones). One key mimic of PACNS is Susac syndrome, a type of vasculopathy that affects the small arteries of the brain, inner ears, and retinas (Beuker, et al.; Cho and Jones). For this patient, audiologic testing will be useful in characterizing hearing loss and other audiologic deficits as well as establishing or excluding a diagnosis of Susac syndrome. Given these findings, the requested audiology services to evaluate for central auditory processing disorder (including: Evoked otoacoustic emissions, limited; Comprehensive audiometry threshold evaluation and speech recognition; Tympanometry and Acoustic Reflex Testing; Evaluation of central auditory function, with report initial 60 minutes; and Evaluation of central auditory function, additional 15 minutes) is medically necessary for this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.