Is a grabber and extended brush medically necessary for a mobile patient with BKA, and how to address his unilateral hearing loss?

Management of Bilateral BKA Patient with Mobility Needs and Unilateral Hearing Loss

A grabber and extended brush are not medically necessary for this mobile bilateral BKA patient, but his unilateral hearing loss requires prompt audiological evaluation and potential amplification to improve quality of life.

Assessment of Mobility Needs

• The patient with bilateral below-knee amputations (BKA) demonstrates good mobility, as evidenced by his ability to independently use his wheelchair and weigh himself 1
• For patients with mobility limitations following stroke or amputation, assistive devices should be prescribed based on medical necessity rather than convenience 1
• The patient's two-year history at the facility without requiring these items, combined with his demonstrated mobility, suggests these are convenience items rather than medical necessities 1

Evaluation of Unilateral Hearing Loss

Initial Assessment

• The complaint of unilateral hearing loss in the left ear requires immediate attention as hearing impairment can significantly impact quality of life and communication 1
• Unilateral hearing loss leads to substantial functional deficits including:
  • Reduced ability to understand speech in noisy environments 2
  • Impaired sound localization abilities 3
  • Potential psychosocial impacts and communication difficulties 4

Recommended Diagnostic Approach

• Refer the patient to an audiologist for comprehensive audiometric testing to determine the type and severity of the hearing loss 1
• Document the hearing impairment in the patient's chart to ensure appropriate follow-up and management 1
• Consider using self-assessment tools such as the Hearing Handicap Inventory for Adults (HHIA) to quantify the impact of hearing loss on quality of life 1, 4

Management of Unilateral Hearing Loss

Amplification Options

• If audiometric testing confirms hearing loss, offer appropriate amplification options based on the type and severity of hearing loss 1
• For unilateral sensorineural hearing loss, consider these options:
  • Conventional hearing aid if there is residual hearing in the affected ear 1
  • Contralateral routing of signal (CROS) hearing aid that places a microphone on the impaired ear and transmits sound to the better ear 1
  • Bone-anchored hearing aid (BAHA) for patients with severe to profound unilateral hearing loss with normal hearing in the contralateral ear 5, 6

Additional Management Strategies

• Implement communication strategies to improve hearing:
  • Look directly at the patient when speaking 1
  • Minimize background noise in the patient's environment 1
  • Consider speech-to-text applications for complex communication situations 1
• For telephone communication, consider amplified phones which may be available through federally funded programs 1

Follow-up Care

• Schedule regular audiologic assessments every 2-3 years or more frequently if necessary 1
• Monitor for changes in hearing status and adjust amplification accordingly 1
• Document resolution, improvement, or worsening of hearing loss and any changes in quality of life after treatment 1

Important Considerations

• Even unilateral hearing loss can cause significant hearing handicap, with studies showing 86% of patients with unilateral sudden sensorineural hearing loss reporting hearing handicap 4
• A trial period with hearing devices before permanent adoption is recommended, as studies show that extended trials help patients develop realistic expectations about device performance 5
• The brain can adapt to unilateral hearing loss through reweighting of auditory cues, but this adaptation may be incomplete without appropriate intervention 3

Conclusion for Facility Response

• Deny the request for grabber and extended brush based on lack of medical necessity given the patient's demonstrated mobility 1
• Prioritize addressing the unilateral hearing loss with prompt referral to audiology for evaluation and potential amplification 1