Does a 59-year-old male with single-sided deafness (SSD) and sensorineural hearing loss (SNHL) in the left ear qualify for a Behind-The-Ear (BTE) hearing aid under policy CM.MED.124?

Coverage Determination for BTE Hearing Aid Under Policy CM.MED.124

This patient does not qualify for a BTE hearing aid under the stated policy criteria, as the audiometric testing fails to meet any of the three required thresholds for medical necessity. 1

Policy Criteria Analysis

The policy CM.MED.124 requires meeting at least one of three specific criteria for air conduction hearing aid approval:

• Criterion 1: Hearing thresholds ≥40 dB HL at 500,1000,2000,3000, or 4000 Hz - NOT MET
• Criterion 2: Hearing thresholds ≥26 dB HL at three of the listed frequencies - NOT MET
• Criterion 3: Speech recognition <94% - NOT MET (patient demonstrates 100% speech recognition)

The authorization request should be denied based on failure to meet policy thresholds. 1

Clinical Context: Single-Sided Deafness with Contralateral SNHL

While the policy denial is appropriate based on audiometric criteria, this clinical scenario warrants consideration of the patient's functional hearing status:

Understanding the Patient's Hearing Profile

• The patient has congenital right ear deafness (non-functional ear) with left ear sensorineural hearing loss that remains above policy thresholds 2, 3
• This represents asymmetric hearing loss rather than true single-sided deafness, as the "better" ear has documented SNHL 3
• The left ear hearing thresholds do not reach the severity requiring amplification under standard criteria 1

Why Conventional Hearing Aids Are Not Indicated Here

Conventional BTE hearing aids require functional cochlear hair cells and adequate residual hearing to provide benefit. 2, 3 The American Academy of Otolaryngology-Head and Neck Surgery indicates that conventional hearing aids are not beneficial for complete unilateral deafness, as they require functional cochlear structures to transduce amplified sound. 2

In this case:

• The right ear is congenitally deaf and would not benefit from any conventional amplification 2
• The left ear does not meet severity thresholds that would justify amplification 1
• Speech recognition at 100% indicates excellent word discrimination, suggesting the left ear is functioning adequately without amplification 1

Alternative Management Considerations

If True Single-Sided Deafness Were Present

If the patient had normal hearing in one ear with complete deafness in the other, appropriate options would include:

• BAHA (Bone-Anchored Hearing Aid): The American Academy of Otolaryngology-Head and Neck Surgery recommends BAHA for single-sided deafness, as it effectively addresses the head shadow effect by transmitting sound from the deaf ear to the functioning ear via bone conduction 2, 4
• CROS devices: Non-surgical alternative using a microphone on the deaf ear to transmit sound to the normal-hearing ear 2, 4
• Cochlear implantation: For single-sided deafness, cochlear implants improve speech perception in noise (43% vs. 15%, P<0.01), sound localization (14° vs. 41° error, P<0.01), and hearing-specific quality of life 4, 5

Current Clinical Recommendation

For this specific patient, no hearing amplification device is medically necessary at this time based on the audiometric evidence. 1 The left ear demonstrates:

• Hearing thresholds better than 40 dB HL at tested frequencies
• Excellent speech recognition (100%)
• Functional hearing capability without amplification

Rehabilitation Counseling

The American Academy of Otolaryngology-Head and Neck Surgery recommends counseling patients about hearing-assistive technology and supportive measures when hearing loss is present, even if amplification is not yet indicated. 1 For this patient:

• Monitor hearing annually: Given the presence of SNHL in the only functional ear, regular audiometric monitoring is essential to detect progression 3
• Establish baseline for comparison: Document current thresholds to identify future changes requiring intervention 1
• Educate about warning signs: Counsel on symptoms that would warrant urgent re-evaluation (sudden hearing loss, significant threshold changes, declining speech discrimination) 1
• Discuss future amplification criteria: If hearing deteriorates to meet policy thresholds (≥40 dB HL at key frequencies OR ≥26 dB HL at three frequencies OR speech recognition <94%), amplification would become appropriate 1

Common Pitfalls to Avoid

• Do not approve hearing aids based solely on patient preference or single-sided deafness diagnosis when audiometric criteria are not met, as this violates evidence-based policy thresholds 1
• Do not confuse asymmetric hearing loss with single-sided deafness requiring BAHA/CROS, as these devices are indicated only when one ear has normal or near-normal hearing 2, 4
• Do not delay appropriate monitoring of the functional ear, as progressive SNHL could render the patient with bilateral severe hearing loss requiring more aggressive intervention 6, 3

The authorization should be denied with recommendation for annual audiometric follow-up and patient education about criteria for future amplification if hearing deteriorates. 1, 3