Health Insurance Coverage of Cochlear Implantation in Single-Sided Deafness and Asymmetric Hearing Loss.

OBJECTIVE

There is increasing interest in providing cochlear implants (CIs) in single-sided deafness (SSD) or asymmetric hearing loss (AHL). CI clinics have experienced a range of outcomes when seeking insurance coverage for patients. The study explored the extent to which CI clinics were able to secure insurance coverage and whether there were differences in successfully gaining such coverage.

STUDY DESIGN

A SurveyMonkey questionnaire was used to collect data from US CI clinicians. Respondents were from all regions of the United States and represented a diversity of clinic types including hospitals, university-based clinics, private clinics, and schools. Data were collected during August-October 2021 from 105 respondents regarding their clinic's experience in gaining health insurance coverage for pediatric and adult patients who had SSD or AHL. Strategies that had been used for gaining coverage after an initial denial were explored. Interviews were conducted with some respondents to gain additional insights beyond the survey.

RESULTS

There was a substantial increase in the number of SSD operations conducted after 2019, the year when the Food and Drug Administration (FDA) manufacturer criteria expanded to include CI in SSD and AHL. Respondents were grouped into four categories based on volume of SSD operations before 2019 (≤10, 11-29, 30-49, and ≥50). The number of SSD operations after 2019 went up in all categories except for the 10 or less category, which declined by 43%. A minority of respondents indicated that they were able to obtain SSD insurance coverage infrequently (5%) or almost never (8%). Peer-to-peer review was the most successful approach to overturning an initial denial. Many clinics note that they are nearly always declined for SSD coverage on the first submission and must appeal.

CONCLUSIONS

There is variability in CI coverage for SSD and AHL. Some health insurance coverage is available for patients of all ages, although some clinics note more difficulty gaining coverage for children younger than 5 years because of the FDA criteria. Clinicians are most successful at gaining coverage after an initial denial with peer-to-peer review, although the process is time-consuming and delays surgery. Efforts to expand access to CIs in SSD for children and adults who may benefit might best be addressed by reflecting on what was done to expand insurance coverage in bilateral deafness-a process that depended on relevant clinical research; research presented to the FDA for guidelines change; information sharing with the general public and constituencies in the hearing loss field including professionals, parent, and consumer organizations; and ongoing advocacy for change with insurers. To date, outcomes research in young children with CI in SSD is limited. Until such research is conducted and published, insurers will continue to argue that other rehabilitative options are approved and available.