National Medical Policy Subject:

Central Auditory Processing Disorder

Policy Number: NMP375 Effective Date*: October 2007 Updated:

March 2016

This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State's Medicaid manual(s), publication(s), citations(s) and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use

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Source National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* Other

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Reference/Website Link

Medicare Learning Network Matters (MLN Matters Number: MM6447 Revised. Change Request #: 6447 September 3, 2010. Revisions and Re-issuance of Audiology Policies: http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM6447.pdf Medicare Learning Network Matters (MLN Matters Number: MM5717. February 29, 2008. Update to Audiology Policies: http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM5717.pdf Use Health Net Policy

Instructions

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Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under “Reference/Website” and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2)

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Current Policy Statement Health Net, Inc. considers diagnostic tests or therapies for the management of central auditory processing disorder (CAPD), also known as auditory processing disorder (APD) investigational due to lack of scientific evidence to support the validity of any diagnostic tests. Although ongoing studies continue, the efficacy of various treatments for CAPD has not been demonstrated.

Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets.

ICD-9 Codes 388.40 - 388.44

Other abnormal auditory perception

ICD-10 Codes H93.2-H93.299 H93.25 H93.3-H93.93

Other abnormal auditory perceptions Central auditory processing disorder Disorders of acoustic nerve

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CPT Codes 92506 92507 92508 92522 92523 92524 92553 92556 92557 92620 92621

Evaluation of speech, language, voice, communication, and/or Auditory processing (Code deleted in 2014) Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) Evaluation of speech sound production with evaluation of language comprehension and expression (eg, receptive and expressive language) Behavioral and qualitative analysis of voice and resonance Pure tone audiometry (threshold); air and bone Speech audiometry threshold with speech recognition Comprehensive audiometry threshold and speech recongnition (92553 and 92556 combined) Evaluation of central auditory function, with report; initial 60 minutes Evaluation of speech fluency (eg, stuttering, cluttering)

HCPCS Codes N/A

Scientific Rationale – Update March 2012 Rabelo et al. (2011) The auditory steady-state response (ASSR) testing is an electrophysiological test that evaluates, among other aspects, neural synchrony, based on the frequency or amplitude modulation of tones. The aim of this study was to determine the sensitivity and specificity of auditory steady-state response testing in detecting lesions and dysfunctions of the central auditory nervous system. Seventy volunteers were divided into three groups: those with normal hearing; those with mesial temporal sclerosis; and those with central auditory processing disorder. All subjects underwent auditory steady-state response testing of both ears at 500 Hz and 2000 Hz (frequency modulation, 46 Hz). The difference between auditory steady-state response-estimated thresholds and behavioral thresholds (audiometric evaluation) was calculated. Estimated thresholds were significantly higher in the mesial temporal sclerosis group than in the normal and central auditory processing disorder groups. In addition, the difference between auditory steady-state responseestimated and behavioral thresholds was greatest in the mesial temporal sclerosis group when compared to the normal group than in the central auditory processing disorder group compared to the normal group. DISCUSSION: Research focusing on central auditory nervous system (CANS) lesions has shown that individuals with CANS lesions present a greater difference between ASSR-estimated thresholds and actual behavioral thresholds; ASSR-estimated thresholds being significantly worse than behavioral thresholds in subjects with CANS insults. This is most likely because the disorder prevents the transmission of the sound stimulus from being in phase with the received stimulus, resulting in asynchronous transmitter release. Another possible cause of the greater difference between the ASSR-estimated thresholds and the behavioral thresholds is impaired temporal resolution. The overall sensitivity of auditory steady-state response testing was lower than its overall specificity. Although the overall specificity was high, it was lower in the central auditory processing

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disorder group than in the mesial temporal sclerosis group. Overall sensitivity was also lower in the central auditory processing disorder group than in the mesial temporal sclerosis group.

Scientific Rationale – Update April 2011 Central auditory processing disorder (CAPD) is also referred to as auditory processing disorder (APD), auditory perception problem, auditory comprehension deficit, central auditory dysfunction, central deafness, and so-called “word deafness.” The diagnosis, management, and even the existence of CAPD remain controversial. According to the National Institute of Deafness and Other Communication Disorders, children with APD often do not recognize subtle differences between sounds in words, even though the sounds themselves are loud and clear. They note that much research is still needed to understand APD problems, related disorders, and the best intervention for each child or adult. Strategies are available to help children with auditory processing difficulties, however, they have not been fully studied. Dawes and Bishop (2010) sought to address the controversy that exists over the extent to which APD is a separate diagnostic category with a distinctive psychometric profile, rather than a reflection of a more general learning disability. Children with an APD diagnosis (N=25) were compared with children with dyslexia (N=19) on a battery of standardized auditory processing, language, literacy and non-verbal intelligence quotient measures as well as parental report measures of communicative skill and listening behavior. A follow-up of a subset of children included a parent report screening questionnaire for Asperger syndrome (Childhood Asperger Syndrome Test). There were similarly high levels of attentional, reading and language problems in both groups. One peculiarity of the APD group was a discrepancy between parental report of poor communication and listening skill disproportionate to expectations based on standardized test performance. Follow-up assessment suggested high levels of previously unrecognized autistic features within the APD group. The investigators concluded children diagnosed by audiological experts as having APD are likely to have broader neurodevelopmental disorders and would benefit from evaluation by a multidisciplinary team. Moore et al (2010) tested the specific hypothesis that the presentation of APD is related to a sensory processing deficit. Randomly chosen, 6- to 11-year-old children with normal hearing (N = 1469) were tested in schools in 4 regional centers across the United Kingdom. Caregivers completed questionnaires regarding their participating children's listening and communication skills. Children completed a battery of audiometric, auditory processing (AP), speech-in-noise, cognitive (IQ, memory, language, and literacy), and attention (auditory and visual) tests. AP measures separated the sensory and nonsensory contributions to spectral and temporal perception. AP improved with age. Poor-for-age AP was significantly related to poor cognitive, communication, and speech-in-noise performance. However, sensory elements of perception were only weakly related to those performance measures and correlations between auditory perception and cognitive scores were generally low. Multivariate regression analysis showed that response variability in the AP tests, reflecting attention, and cognitive scores were the best predictors of listening, communication, and speech-in-noise skills. The authors concluded presenting symptoms of APD were largely unrelated to auditory sensory processing. Response variability and cognitive performance were the best predictors of poor communication and listening. They suggest that APD is primarily an attention problem and that clinical diagnosis and management, as well as further research, should be based on that premise.

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Rosen et al (2010) evaluated auditory and cognitive abilities in a group of children referred for an auditory evaluation on the grounds of a suspected auditory processing disorder (susAPD), and in age-matched children who were typically developing, in order to determine the extent to which any deficits in cognitive abilities could be related to auditory deficits. A battery of auditory and cognitive tests was applied to 20 susAPD school-age children, all reported as having listening/hearing problems but performing within normal limits for standard audiometric assessments. Also tested was a group of 28 age-matched controls. The auditory tasks consisted of two simple same/different discrimination tasks, one using speech, and one nonspeech. The cognitive evaluation comprised a vocabulary test, a test of grammar and four non-verbal IQ measures. Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) were assessed in the susAPD group through a standardized questionnaire. A significant proportion of susAPD children appeared to display genuine auditory deficits evidenced by poor performance on at least one of the auditory tasks, although about 1/3 had no detectable deficit. Children in the susAPD group scored consistently lower than the controls on cognitive measures that were both verbal (vocabulary and grammar) and non-verbal. Strikingly, susAPD children with relatively good auditory performance did not differ in cognitive ability from susAPD children with poor auditory performance. Similarly, within-group correlations between auditory and cognitive measures were weak or non-existent. Measures of ADHD did not correlate with any aspect of auditory or cognitive performance. The investigators concluded although children suspected of having APD do show, on average, poorer performance on a number of auditory tasks, the presence or absence of an auditory deficit appears to have little impact on the development of the verbal and non-verbal skills tested in this study.

Scientific Rationale – Initial Central Auditory Processing (CAP) refers to the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Central auditory processes are the auditory system mechanisms and processes responsible for sound localization and lateralization; auditory discrimination; temporal aspects of audition including: temporal resolution, temporal masking, temporal integration and temporal ordering; auditory performance with competing acoustic signals and auditory performance with degraded signals. According to the American Speech-Language Hearing Association (ASHA), central auditory processing disorder (CAPD), also known as auditory processing disorder (APD), refers to difficulties in the perceptual processing of auditory information in the CNS as demonstrated by poor performance in one or more of the skills noted above. CAPD It is a complex and heterogeneous group of auditory-specific disorders usually associated with a range of listening and learning deficits. Children or adults suspected of CAPD may exhibit a variety of listening and related complaints such as difficulty understanding speech in noisy environments, following directions, and discriminating (or telling the difference between) similar-sounding speech sounds. The child may have difficulty with spelling, reading, and understanding information presented verbally in a classroom. Some individuals may also have behavioral, emotional or social difficulties. CAPD often co-exists with other disabilities such as learning disabilities or dyslexia, attention deficit disorder (ADD), autism, autism spectrum disorder, specific language impairment, pervasive developmental disorder, or developmental delay. The cause of CAPD is unknown and its relation to coexisting disorders, such as ADHD is poorly understood. According to Chermak (2002) a comprehensive assessment is necessary for the accurate differential diagnosis of CAPD from other "look-alike" disorders, most notably ADHD and language processing disorders, however, at

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present, CAPD is not very well specified, and standardized diagnostic tests are lacking. The diagnosis, management, and even the existence of a modality-specific dysfunction remain controversial. At this time there is no universally accepted method of screening for CAPD. The Screening Test for Auditory Processing Disorders (SCAN) tests both monotic and dichotic listening abilities and has been proposed as a standardized method for determining the potential of central auditory processing disorder (CAPD) in children between the ages of 3 and 11 years. At this time, there is no accepted “gold standard” test battery for establishing CAPD. Behavioral and electrophysiologic tests have been proposed to assess central auditory function. The behavioral tests are often broken down into four subcategories, including monaural low-redundancy speech tests (e.g, compressed speech test, filtered speech test), dichotic speech tests (e.g., staggered spondaic word test, dichotic digits test), tests of temporal processing, and binaural interaction tests. Central auditory processing assessments may not be appropriate for children with significant developmental delays (i.e., cognitive deficits) or children under the age of 7 years. Treatment and management goals are deficit driven. No pharmacologic agent has been demonstrated as effective specifically for CAPD. Interventions for CAPD focuses on improving the quality of the acoustic signal and the listening environment, improving auditory skills, and enhancing utilization of metacognitive and language resources. The National Institute on Deafness and Communication Disorders notes that much research is still needed to understand CAPD problems, related disorders, and the best intervention for each child or adult. Researchers are currently studying a variety of approaches to treatment. Controlled case studies and randomized clinical trials are needed to ascertain systematically the relative efficacy of various treatment and management approaches. Vanniasegaram et al. (2004) compared the auditory function of normal-hearing children because of listening/hearing problems (suspected auditory processing disorders [susAPD]) with that of normal-hearing control children. Sixty-five children with a normal standard audiometric evaluation, ages 6-14 yr (32 of whom were referred for susAPD, with the rest age-matched control children), completed a battery of four auditory tests: a dichotic test of competing sentences; a simple discrimination of short tone pairs differing in fundamental frequency at varying interstimulus intervals (TDT); a discrimination task using consonant cluster minimal pairs of real words (CCMP), and an adaptive threshold task for detecting a brief tone presented either simultaneously with a masker (simultaneous masking) or immediately preceding it (backward masking). Regression analyses, including age as a covariate, were performed to determine the extent to which the performance of the two groups differed on each task. Age-corrected z-scores were calculated to evaluate the effectiveness of the complete battery in discriminating the groups. The performance of the susAPD group was significantly poorer than the control group on all but the masking tasks, which failed to differentiate the two groups. The CCMP discriminated the groups most effectively, as it yielded the lowest number of control children with abnormal scores, and performance in both groups was independent of age. By contrast, the proportion of control children who performed poorly on the competing sentences test was unacceptably high. Together, the CCMP (verbal) and TDT (nonverbal) tasks detected impaired listening skills in 56% of the children who were referred to the clinic, compared with 6% of the control children. Performance on the two tasks was not correlated. The authors concluded that two of the four tests evaluated, the CCMP and TDT, proved effective in differentiating the two groups of

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children of this study. The application of both tests increased the proportion of susAPD children who performed poorly compared with the application of each test alone, while reducing the proportion of control subjects who performed poorly. The findings highlight the importance of carrying out a complete auditory evaluation in children referred for medical attention, even if their standard audiometric evaluation is unremarkable. Neijenhuis et al. (2003) evaluated a test battery comprising six different tests for auditory processing disorders evaluated in a group of 49 adults and children (age 857 years) with auditory complaints despite normal audiometric thresholds. Percentile scores were derived from normal control groups (n = 132) to determine whether a subject passed or failed a test. A composite score was computed to reflect a general score on all the auditory processing tests. In order to gain insight into underlying auditory processes, factor analysis was performed. Normal scores on all the tests were seen in five subjects. The remaining 44 subjects had at least one test score that was below the cut-off point (10th percentile). Factor analysis provided evidence for a model comprising four auditory components: auditory sequencing, word recognition in noise, auditory closure, and auditory patterning. The authors concluded this model could be useful in the interpretation of scoring patterns. They noted, although there were some differences in scoring patterns between the children and adults, the test battery proved to be useful in both groups. A review on auditory processing and the development of language and literacy (Bailey and Snowling, 2002) found that evidence for basic auditory processing impairments associated with dyslexia and specific language impairment is inconsistent. It appears that not all children with language difficulties have nonverbal auditory processing impairments, and for those who do, the impact on language development is poorly understood. The authors stated that advances in the understanding of the role of auditory processing in the genesis of language difficulties have been hampered theoretically by a lack of agreement regarding the relationship between basic auditory skills, speech perception and phonological processing abilities, and also methodologically by frequent uncontrolled group differences in experimental studies. Well-designed studies are needed to ascertain the extent to which there are auditory-specific learning disabilities. According to a review (Cacace and McFarland, 1998), the rationale to evaluate for CAPD in school-aged children is based on the premise that an impairment in auditory perception can be the underlying cause of many learning problems, including specific reading and language disabilities. They note however, "the existing literature on this topic has not clarified the "true" nature of the problem, and has left many questions about this disorder unanswered. They suggest that multimodal perceptual testing is one logical approach to help clarify this area of investigation." However, there is insufficient scientific evidence in the peer review literature to validate this theory. In summary, central auditory processing disorder (CAPD) is fraught with problems arising from confusion concerning the clinical evidence of the disorder. The diagnosis, management, and even the existence of an auditory-specific perceptual deficit are controversial. The rationale to evaluate a school-aged child for CAPD is based on the assumption that perceptual dysfunctions limited to a single sensory modality underlies many learning problems including specific reading and language disabilities. A fundamental issue in this area is whether convincing empirical evidence exists to validate this proposition. Difficulty in validating CAPD as a diagnostic label is due in large part to use of the unimodal inclusive framework, which has biased the

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diagnosis to favor sensitivity of test results over documenting the specificity of the deficit. Indeed, empirical research documenting modality-specific auditory-perceptual dysfunction in this population is scarce. Therefore, the existing literature on this topic has not clarified the "true" nature of the problem, and has left many questions about this disorder unanswered. A major controversy revolves around characterizing the disorder as a unique cluster of behaviors reflecting impairment in some underlying mechanism(s) or as a disorder defined on the basis of performance on a set of tests. The ultimate merit of any approach to CAPD intervention depends on the efficacy of the treatment. Although theoretically based treatment approaches have been proposed, there have been very few convincing demonstrations of the efficacy of CAPD treatments. Poor design, limited scope, and/or small size of most efficacy studies leaves us unable to judge this body of research. Three conceptual stumbling blocks, including heterogeneity of the population studied, varied treatment goals and endpoints, and demonstration of true treatment efficacy hinder proper evaluation.

Review History October 2007

Medical Advisory Council, initial approval

April 2011

Update. No revisions.

March 2012

Update. No revisions.

March 2013

Update. No revisions. Coding updates.

March 2014

Update. No revisions. Coding updates.

March 2015

Update – no revisions

March 2016

Update – no revisions

This policy is based on the following evidenced-based guidelines: American Speech-Language Hearing Association. Position Statement. (Central) Auditory Processing Disorders—The Role of the Audiologist. 2005. Available at: http://www.phon.ucl.ac.uk/courses/spsci/audper/ASHA%202005%20CAPD%20st atement.pdf 2. American Speech-Language Hearing Association. Technical report. Central Auditory Processing Disorders. April 2005. 3. Hayes. Health Technology Brief. Electrophysiological Testing for Diagnosing Central Auditory Processing Disorder (CAPD). December 10, 2009. Updated December 5, 2011. Archived January 10, 2013. 4. American Psychiatric Association. Language disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.42. 1.

References – Update March 2016 1. 2. 3.

Barrozo TF, Pagan-Neves Lde O, Vilela N, et al. The influence of (central) auditory processing disorder in speech sound disorders. Braz J Otorhinolaryngol. 2016 Jan-Feb;82(1):56-64. Boscariol M, Casali RL, Amaral MI, et al. Language and central temporal auditory processing in childhood epilepsies. Epilepsy Behav. 2015 Dec;53:1803. Heine C, O'Halloran R. Central Auditory Processing Disorder: a systematic search and evaluation of clinical practice guidelines. J Eval Clin Pract. 2015 Dec 21.

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References – Update March 2015 1. 2.

Azouz HG, Kozou H, Khalil M et al. The correlation between central auditory processing in autistic children and their language processing abilities. Int J Pediatr Otorhinolaryngol. 2014 Dec;78(12):2297-300. Lang-Roth R. Hearing impairment and language delay in infants: Diagnostics and genetics. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2014 Dec 1;13:Doc05.

References – Update March 2014 1. Terband H, Maassen B, Guenther FH, et al. Auditory-motor interactions in pediatric motor speech disorders: Neurocomputational modeling of disordered development. J Commun Disord. 2014 Jan 21. pii: S0021-9924(14)00002-1. doi: 0.1016/j.jcomdis.2014.01.001. [Epub ahead of print]

References – Update March 2013 1. 2.

Carter J, Musher K. Etiology of speech and language disorders in children. UpToDate. April 5, 2012. Updated July 1, 2013. Smith R JH, Gooi A. Etiology of hearing impairment in children. UpToDate. May 23, 2012.

References – Update March 2012 1. 2.

Lagace J, Jutras B, Gagne JP. Auditory processing disorder and speech perception problems in noise: Finding the underlying origin. Am J Audiol. 2010;19(1):17-25. Rabelo CM, Schochat E. Sensitivity and specificity of auditory steady-state response testing. Clinics (Sao Paulo). 2011;66(1):87-93.

References – Update April 2011 1. 2. 3. 4. 5. 6. 7. 8.

Brosch S, Reiter R, Imgrunt J, et al. How do results in BAKO 1-4 and H-LAD-test correlate with auditory processing? Laryngorhinootologie. 2010 Jul; 89(7): 4107 Dawes, P, Bishop, DV. Psychometric profile of children with auditory processing disorder and children with dyslexia. Arch Dis Child 2010; 95:432. Moore, DR, Ferguson, MA, Edmondson-Jones, AM, et al. Nature of auditory processing disorder in children. Pediatrics 2010; 126:e382. National Institutes of Health. National Institute of Deafness and Communication Disorders. Auditory Processing Disorder in Children. Available at: http://www.nidcd.nih.gov/health/voice/auditory.html Rosen S, Cohen M, Vanniasegaram I. Auditory and cognitive abilities of children suspected of auditory processing disorder (APD). Int J Pediatr Otorhinolaryngol. 2010 Jun; 74(6): 594-600. Schochat E, Musiek FE, Alonso R, Ogata J. Effect of auditory training on the middle latency response in children with (central) auditory processing disorder. Braz J Med Biol Res. 2010 Aug; 43(8): 777-85. Simões MB, Schochat E. Central) auditory processing disorders in individuals with and without dyslexia. Pro Fono. 2010 Oct-Dec; 22(4): 521-4 Wilson WJ, Jackson A, Pender A, et al. The CHAPS, SIFTER, and TAPS-R as predictors of (C) AP skills and (C) APD. J Speech Lang Hear Res. 2011 Feb; 54(1): 278-91

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References – Initial 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Cameron S, Dillon H. Development of the Listening in Spatialized NoiseSentences Test (LISN-S). Ear Hear. 2007 Apr;28(2):196-211. Dlouha O, Novak A, Vokral J. Central auditory processing disorder (CAPD) in children with specific language impairment (SLI). Central auditory tests. Int J Pediatr Otorhinolaryngol. 2007 Jun;71(6):903-7. Moore DR. Auditory processing disorders: acquisition and treatment. J Commun Disord. 2007 Jul-Aug;40(4):295-304. Palfery TD, Duff D. Central auditory processing disorders: review and case study. Axone. 2007 Spring; 28(3): 20-3. Cherry R, Rubinstein A. Comparing monotic and diotic selective auditory attention abilities in children. Lang Speech Hear Serv Sch. 2006 Apr;37(2):13742. Fuente A, McPherson B, Munoz V, et al. Assessment of central auditory processing in a group of workers exposed to solvents. Acta Otolaryngol. 2006 Dec;126(11):1188-94 Moore DR. Auditory processing disorder (APD)-potential contribution of mouse research. Brain Res. 2006 May 26;1091(1):200-6 Keller WD, Tillery KL, McFadden SL. Auditory processing disorder in children diagnosed with nonverbal learning disability. Am J Audiol. 2006 Dec;15(2):10813 Kiese-Himmel C, Kruse E. Critical analysis of children with suspicion of auditory processing disorders. Laryngorhinootologie. 2006 Oct;85(10):738-45. Cacace AT, McFarland DJ. The importance of modality specificity in diagnosing central auditory processing disorder. Am J Audiol. 2005 Dec;14(2):112-23 Katz J, Tillery KL. Can central auditory processing tests resist supramodal influences? Am J Audiol. 2005 Dec;14(2):124-7 Musiek FE, Bellis TJ, Chermak GD. Nonmodularity of the central auditory nervous system: implications for (central) auditory processing disorder. Am J Audiol. 2005 Dec;14(2):128-38 Meister H, von Wedel H, Walger M. Psychometric evaluation of children with suspected auditory processing disorders (APDs) using a parent-answered survey. Int J Audiol. 2004 Sep;43(8):431-7. Ptok M, Blachnik P, Schonweiler R. Late auditory potentials (NC-ERP) in children with symptoms of auditory processing and perception disorder. With and without attention deficit disorder Strauss DJ, Delb W, Plinkert PK. Objective detection of the central auditory processing disorder: a new machine learning approach. IEEE Trans Biomed Eng. 2004 Jul;51(7):1147-55. Vanniasegaram I, Cohen M, Rosen S. Evaluation of selected auditory tests in school-age children suspected of auditory processing disorders. Ear Hear. 2004 Dec;25(6):586-97. Neijenhuis K, Snik A, van den Broek P. Auditory processing disorders in adults and children: evaluation of a test battery. Int J Audiol. 2003 Oct;42(7):391400. Bailey PJ, Snowling MJ. Auditory processing and the development of language and literacy. Br Med Bull. 2002;63:135-46 Chermak GD. Deciphering auditory processing disorders in children. Otolaryngol Clin North Am. 2002 Aug;35(4):733-49 Friel-Patti S. Clinical Decision-Making in the Assessment and Intervention of Central Auditory Processing Disorders. Language, Speech, and Hearing Services in Schools Vol.30 345-352 October 1999.

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21. Cacace AT, McFarland DJ. Central auditory processing disorder in school-aged children: a critical review. J Speech Lang Hear Res 1998 Apr;41(2):355-73. 22. Moss WL, Sheiffele WA. Can we differentially diagnose an attention deficit disorder without hyperactivity from a central auditory processing problem? Child Psychiatry Hum Dev. 1994 23. Keith RW. Interpretation of the Staggered Spondee Word (SSW) test. Ear Hear. 1983 Nov-Dec;4(6):287-92. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. states, prior notice or website posting is required before an amendment is deemed effective.

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No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member’s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the

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benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. The Policies do not replace or amend the Member’s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.

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