legal final paper

Stacey-Ann Ellis Legal and Ethical Issues

COCHLEAR IMPLANTS Ambiguities involved in the distribution of services in policies from health service corporations and judicial Involvement.

Ambiguities involved in the distribution of services in policies from health service corporations

and judicial Involvement. 1

Dear American Speech-Language Hearing Association (ASHA),

Recently, you have requested of me a policy analysis of current policies regarding

Cochlear Implants and its access through insurance coverage in terms of distribution of services

and the ambiguities involved in the distribution of resources. I have searched and found three

corporate policies and I have also found judicial involvements to help me get started. In my

understanding Cochlear Implantation have been on the rise for over 10 years and each year more

individuals opt for the chance to hear again with the help of these devices. It is rather fascinating

that even though we are in a technological age, and many health issues are solved through

technological advances, there are still problems with cochlear implants due to ideals held

personally or professionally that may hinder the well-being of another.

While exploring the topic of Cochlear Implants is not new, doing a policy analysis on it

is. This project will force me to think outside the box and become creative with solutions. With

this new found technology, parents opt for their child to have this option in order for the child to

communicate verbally and not just sign language (if at all). Many older individuals are now

opting to get cochlear implants as means of normalizing their daily lives back to the way it was,

or their hearing has gotten much worst that they need it, not just to maintain a healthy life, but to

also keep their vocation open and not having to give their work up due to the degree of the loss.

While the Deaf Community does not agree with this technology as it takes away from them,

some people are impartial on it and others are all for it. This policy analysis will explore

difficulties face regardless of the increased population and demand of the Deaf and cochlear

implants. I would like to also explore the possibilities of where there may be a fair chance for

people who needs the implantation.

Sincerely, Stacey-Ann Ellis



Policy Analyst

Introduction

Throughout the world, there is an increasing population of individuals with some degree

of hearing loss whether it is congenital, pre-lingual or post-lingual. There are sources to help

detect hearing loss much earlier than a century ago, but there are also factors that induce this

problem within our environment every day. Due to the fact that this awareness and ways so solve

the issues are increasing and becoming more creative, why then are insurance companies being

reluctant to take part in the solution to the problem and instead filling their policies regarding the

use, access and coverage to cochlear implants with ambiguities? With this Policy analysis, we

will explore and utilize information from the current status of corporate policies, judicial

involvements, policies, regulations, laws, and ethics to come up with feasible and a much needed

solutions. As we look to the future, hopefully health coverages in all areas of health care will

have little to no ambiguities to present a brighter future for the wellbeing of everyone.

Demographics

The United States have a population of approximately 320 million people. According to

the National Institute of Health (NIH), about 3 out of 1,000 children in the United States are born

with detectable hearing loss and 1 in 8 people aged 12+ have hearing loss in both ears, which is

approximately 30 million people. Hearing loss is the deviation of one’s hearing from what is

considered normal. An individual who has normal hearing is able to hear between -10 to 25

decibels; decibel is a logarithmic unit which is used to express the ratio between two values of

physical quantity; power or intensity. The total amount of people worldwide who have received

cochlear implants is 324, 200; about a tenth of the overall United States population. Cochlear

implant is a small device, implanted into the mastoid bone, behind the ears, which conducts

sound wave and sends the noise to a sound processor, which then stimulates the auditory nerve



and tells the brain what kind of sound they are hearing. In the United States there were 58, 000

adults and 38,000 children, with a total of 96, 000 individuals who received the implant.

Deafness or hard of hearing is a growing concern globally due to the advances in

technology, both in the effects of it and detecting of hearing loss. According to the American

Speech-Language and Hearing Association, between 1970 and 2000, the number of Americans

with hearing loss doubled. Increased exposure to noise from our environment or personal

recreational technology, drugs/medications, illnesses or presbycusis due to aging, all factors in

the causes of hearing loss outside of it being congenital. According to ASHA, as many as

738,000 individuals have severe to profound hearing loss, which means that the hair cells in their

cochlea is mostly or completely destroyed and can no longer receive benefits from assistive

devices like hearing aids. Most people rather verbal communication over sign language.

Therefore, many people will opt for the choice of an implant if they became a candidate to

receive its benefits. Approximately 3 out of every1000 children are born with some level of

hearing loss each year.

Hearing loss is debilitating and is a health concern. Over the years, one’s hearing health

decreases naturally as we get older or due to exposure of different environmental factors such as:

a lawnmower, blow dryer, a concert, drilling, and explosions among others affects it. When an

individual who already have difficulties hearing and choose not to wear aid, they are at risk for

greater disparities. “Among adults aged 70 and older with hearing loss who could benefit from

hearing aids, fewer than one in three or 30 percent has ever used them. Even fewer adults aged

20 to 69 (approximately 16 percent) who could benefit from wearing hearing aids have ever used

them.” In other words, older adults who are aged 70+, approximately 70% of them do not wear

their hearing aid. Adults between the ages of 20-69, 84% of those who could also benefit from



wearing aids do not wear them. Most people do not realize that their hearing is getting worse

each time there is harsh exposure and will deny or bargain about whether or not they have

hearing loss, until they can no longer put it off and begin to accept it. The chances of needing a

cochlear implant increases much immensely the longer one neglects hearing care.

Recent Charts

The above 2 graphs from the From the NIH, National Institute on Deafness and Other

Communications Disorders (NIDCD), are comparing the 2010 target lines for each device at the

minimum amount of people to receive aid. These target lines are compared to 2001 in cochlear

implants and 2006 in hearing aids. The goal in both is to provide equal amount of each aid across

all of the population regardless of age or sex. In 2001 the target for cochlear implant was 100 per

10,000 across the board, while in hearing aids the target was more along the line of

approximately 180 per 1,000. This is to say that hearing aids in comparison to cochlear implants

are more widely accepted.

The individuals who are more at risk for noise induced hearing loss are among males

between the ages of 20 and 60. (This is shown in the charts below). Babies in both sexes have the



least amount of likeliness of having hearing loss, but there is an increased level by the age of

three, due to their vulnerability and increased exposure to diseases like meningitis. African

American men, shortly followed by White men and then Hispanics were the trends in 2005,

though in the 1900s, it was the other way around. Earlier, it was noted that hearing loss has been

increasing over the years and this chart supports this fact by showing that even though, the

amount of whites' hearing loss has decreased since the 1900s, there is an overall increase among

all three of the races, and it would be safe to assume the same is happening among all races.

Older Charts


and judicial Involvement. 6 By the Gallaudet University Library1

By the Gallaudet University

The above data from the older chart captures information approximately 25 years prior

today. This is a major reflection as hearing loss is a growing issue. The population when these

data were taken was 235,688,000 and today we are at approximately 320,600,000 and counting

each second. With this comparison of population, we can predict that today has a much larger

population of the hearing impaired. There have been many technological advances that are either

helping or hurting our hearing sensitivity, but our income and access to care also affects us.

In one of the older charts, it reads that the white population, comparing to the black

population, is twice as likely to have hearing loss, but in the more recent charts, it shows that

1 * Gallaudet University, the world's only university with programs and services specifically designed to

accommodate deaf and hard of hearing students, was established in 1864 by an Act of Congress, and its charter was

signed by President Abraham Lincoln.



black men between the ages of 20 and 60 are at higher risks for hearing loss. This hold

consistency from the charts in the early 1990’s in the charts above. According to The Ear

Foundation in the UK at the National Institute for Health and Clinical Excellence, “…those using

sign language and those from minority ethnic families may have difficulty in accessing

information about implantation.” Minorities generally have less coverage in care, and with

cochlear implants, the same applies. According to The American Academy of Otolaryngology –

Head and Neck Surgery, cochlear implants can cost up to $100,000. The U.S census states state

that the average Black Median Household income in 2011 is $33,460 and whites with $55,412.

The African community had 19.5% of people who were uninsured and the white population at

14.9%. Interestingly, the people who do not make a lot of income are the ones that are more

prone to having hearing loss, which are the minorities and in this case the African American. The

cost of cochlear implants among the middle class and lower class are expensive and hard to

acquire due to insufficient funds, much less to afford an almost $100,000 implant and this is

where insurance would play a major role in aiding.

Insurance policies needs to incorporate more for more people to if they wished to have

the implantation. With the help of the American Speech-Language Hearing Association bringing

forth their concern, this problem will be carefully revised and a preferable solution will be

implemented. Even so, there are limited inclusion of these details in health policies though the

issue is a growing concern. Hearing Health Care should help influence the cost and quality of

Cochlear Implants to improve access and with this problem being stated, work is to be done in

order to have a feasible resolution.

The hearing loss population is growing, therefore there will be increased concerns as the

years goes on. The baby boomers, born between 1946 and 1964, are getting into their retirement



ages and additional health issues arises as the younger generation gets older. As the concerns

grow, the need for hearing technology increased in demand as well. Cochlear implantations are

performed in adults and in children as young as 12 months old, with current experiments of

children at younger ages. Young children are prone to sickness which is also a factor in the

demographics and with the advancement of technology, disparities can be caught much sooner

than in the past at an increasing rate. In the recent chart for cochlear implants in 2001, the

amount of children who received the implantation was 1,035, which was way over all the other

categories along with the projected goal for 2010. This means that though many people are

against the implantation, parents are providing their children with implantation in order to have a

chance at hearing in the future at a high rate. Hopefully with this policy review, much will be

mentioned and resolutions will be applied to all of the presented problems, with the help of

various institutions.

As the insurance companies gain awareness over the years, more corporations are

opening their policies and allowing coverage for people with cochlear implants and related care.

Some insurance companies have ambiguities in their coverage, which leads to misunderstanding

on the patient’s part thinking that they are covered when it may not be the case. As time

progresses and hearing loss and the solution of cochlear implants become more accepting

throughout society, insurance companies will hopefully loosen reigns on what is covered in

terms of cochlear implants. After all, though it may be implanted in the ear and may not be

aesthetically appealing for the most part, an implant is an implant no matter how one tries to

view it. Accepting of some implants over others may not create the smoothest response from

beneficiaries and therefore may result in change for the future generations of people and cochlear

implants.



Policies

Public Law 108-446

108th Congress

20 U.S.C. § 1400 : US Code – Section 1400

According to the regulation of the Individuals with Disabilities Education Act (IDEA),

related services for children with cochlear implants do not exist because the devices are implants.

Other individuals with hearing disparities who uses assistive devices as well as hearing aid,

receives services like: interpretation, psychology, physical and occupational therapy, access to

Speech-Language Pathologists and Audiologists along with school nurses and many others.

Those are all services that are beneficial to a child with cochlear implant(s), who perhaps may

need it more due to the loss of their residual hearing (remaining function of hair cells that

triggers hearing) has been wiped clean and replaced with artificial electrode arrays to trigger the

8th cranial nerve; which runs along the line of the cochlea to the brain. People with hearing aids

have the ability to hear some sounds depending upon the pitch and needs help in order to pick up

sounds of lower decibels. The people who need more help, are the ones that do not receive

enough of it because a child with cochlear implant creates a controversial issue. The hearing

impaired need every help they can get access to in order to understand the noises in their

environment which are transmitted through their devices(s). Therefore, individuals with cochlear

implant have a harder time coping and need the same or more services that are rendered to

individuals who receives the above hearing aids.

According to section (b)(2), nothing is limited to the child in related services that are

determined by the Individual Education Program (IEP) team to be necessary for the child to

receive Free and Appropriate Public Education (FAPE). In my understanding, this is saying that

by denying the child related services that would help with their advancing, does not limit them or



perhaps affect them in receiving FAPE, as it normally would have with other children who have

hearing impairments and other disabilities. This is tricky because we now have to define what

appropriate means. In my understanding appropriate means something that is beneficial to the

individual based on their own specific needs. According to the Cambridge dictionary,

appropriate means to be 'suitable or right for a particular situation or occasion'. Would it not be

right or deem necessary, that all the children with hearing disparities be treated with the same

level of interest and not discriminated on whether or not they have an implanted device or not?

Or to provide the child with what they need as an individual and not as a group? Is it not

appropriate that the child wearing these devices receive aid to help him or her not just meet the

bare minimum across the board, but also be given the opportunity to achieve beyond that? Why

are these regulations so ambiguous in their treatment? Cochlear implant falls under Audiology,

yet Audiological services are not rendered if a child has an implantation, which includes cochlear

implants. IDEA seem to be okay with helping out children as much as they can, but the deal

breaker seem to be, implantation. As soon as implantation is brought up, the regulations set forth

takes back all the potential support that exists.

Excellus BlueCross BlueShield Medical Policy, § 7.01.26 (2014)

This policy looks at the benefit of what is given and the effectiveness along with the

training associated with getting the cochlear implantation. Before the Bilateral implantation is

done, if at all needed, it has to be deemed necessary by the doctors when a unilateral with a

hearing aid in the other ear is not making a difference. A cochlear implant is a prosthetic device

that is supposed to help you in areas that your body can no longer perform, but neither is it a

replacement, though it may act like such. A cochlear implant will never have the normal

capability or capacity of the natural cochlea. Cochlear implants are great inventions, but the

speech reading training for approximately 25 hours over 6-10 meetings, is what makes the



processing and understanding through the device increase or beneficial along with mapping.

Speech reading helps to look at an individual’s mouth and match their voice and the movement

of their lips with lip reading in order to match what the implant is picking up. There is an

increased performance when all these sessions are taken and also taken seriously. When a child

at an early age receives the implants, it is important for them to have substantial training in these

areas because it helps them to become better at their speech and understanding of speech whether

pre-lingual or post-lingual. This allows them to have the ability to perform in almost or within

the percentile of other children that are their age. For adults this may be also needed to help them

familiarize words with mouth movement. If it is the case it is the case that the adult has been deaf

for most of their life and has just gotten a new implantation, their approach may be similar to that

of a pre-lingual child because they never had the chance to begin speaking and hearing before

they went deaf.

Coverage for an aesthetic upgrade is not allowed as it is not considered a medical issue.

Unilateral implantation is covered, but a bilateral implantation is recommended especially for the

localization of sounds (picking up where the sound is coming from around you) and head

shadow effect (how long does it take for the sound to reach one ear in comparison to the other).

Anomalies (deviation from the norm) that obstructs the effectiveness of the implant would not

help the implantation. If it is a reoccurring situation, like ossification within the ear or ear

infections, it is not necessary to put the implantation in as there would be an ongoing medical

evaluation and follow-up. Ossification of the bones within the ear would defeat the intent of the

aid and be uncomfortable for the patient and for the insurance companies as it would be

considered wasteful resources. Aesthetic upgrades are not covered because it does not improve

one’s hearing ability. The corporation cares about minimizing your difficulty, not about



increasing aesthetic appearance to either please yourself or the eyes of another, which is

essentially understandable.

The implantation is a process that requires a lot of aid in order to pave the way for

children or adults who struggles with hearing impairments. There needs to be access to services

like speech reading and lip reading and if that does not take place then the individual may suffer.

Training is what fine tunes the functionality of the implant and coverage provides the support

that the patient needs in order to get over said obstacle in their life and their ability to live a

happy life. This medical policy under BlueCross BlueShield seems to have the understanding of

the necessary services that may benefit the individual, unlike the Individual with Disabilities

Education Act above. BlueCross BlueShield provide services to the people with cochlear

implants down to 12 months of age. Though IDEA is a school program regulation that affects all

children, services have to be rendered to children hearing disparities as well to show them that

they are just as important as anyone else. Denying a child services at an early age, who already

had or have disadvantage(s) against them, does not need another disadvantage when it comes to

the one thing that is supposed to set them free, education though is not always the case.

Aetna Clinical Policy Bulletin: Cochlear Implants and Auditory Brainstem Implants § 0013

(2015)

Aetna is one of the few insurance policies that understands what services are needed in

order to maximize the potential of a cochlear implant. Aetna considers unilateral or bilateral

implantation necessary prosthetic for individuals of age 18 and above. They also have provisions

available for children who are as young as 2 months old in trials. This goes against both the

beliefs of many ethics committee along with the Deaf communities, but Aetna seem to view an

implantation as a necessity in order to function as normally as possible in society. There is a



criteria in which the child or the adult needs to fall under in order to be the perfect candidate and

procedures like their pure tone average, decibels they could hear at, test scores on speech

recognition, understanding of phrases, sentences, vowels, consonants, phonology and the percent

correct they get back that has to fall within a certain range based on their age. All the children in

the trial with various ages, were followed over a four year period and data was collected showing

that the children had no delays and were right where they needed to be in accordance to cultural

and societal norms. The children showed great potential just as much as any other child, which

goes to show how delicate the implantation is in terms of timing of implantation and learning

language among other developments throughout childhood. Timing is also important for adults;

the sooner after losing their hearing they get help, the better their perceptibility will be with an

implant rather than years after. Once there is hearing loss, it never gets better, it just gets

progressively worst over the years so quick action may help. This is the goal that is aimed for;

providing access to hearing devices that allows an individual that has an impairment to be ranked

in the same percentile in performance as the same as their counterpart with normal hearing. This

insurance does not frown upon unilateral implants, but knows that bilateral would be better and

they seem to work to the best of their potential to alleviate any issues that may be present.

BlueCross BlueShield above, supports the usage of both implants, but they make sure that any

other potential devices that can possibly be used in contingent with the implant would be used in

order to save money while exploring different solutions.

Aetna allowing the eradication of the problem from an early age is an effective choice.

Each deaf child according to ASHA cost approximately $1 million lifetime cost if a deaf child go

unnoticed. It would cost a fraction of that cost when the problem is taken care of both for the

family of the individual and for the insurance companies. Clearly taking care of the issue the

sooner is the better as there is less associated problems as the individual gets older. If IDEA had



this same perspective, many issues would be resolved. A child with hearing disability who

differs from another child who wears hearing aid, and him wearing an implantation should not

have less care within the schooling system. Aetna solving the problem for the child before he

reach school age, prevents unfair regulations within IDEA and sets the child up for a better

future.

With the promoting of cochlear implants at an early age, there are potential costs being

eradicated. Children and adults that suffers from disabilities overall, cost a lot of money. If one

child who slips through the crack cost a million dollars, it would and does cost millions each year

in comparison to over a lifetime for thousands of children and adults. Avoiding the coverage of

the children may seem alright for the insurance companies in terms of short term occurrences,

but in terms of long term, they will suffer immensely. Covering the implants will slow down the

progression of loss or completely solve the problem, essentially saving money. If that cost can be

immensely cut, the companies would be taking smarter steps in order to save money in the

future, even if the ‘right now’ costs are high. Future projections are more important than a cost

for right now, if the benefits later will be greater.

IDEA provides services for all children who have disabilities of any kind and also

children with hearing aids. However, IDEA, does not provide services for children who have/has

implantation(s) because it is an implant and therefore is unnatural. All the services that are

provided for the other children and the same ones that may benefit the child with cochlear

implants. BlueCross BlueShield seems to have grasped the understanding that IDEA seem to

lack; the implantation is a necessary one. Aetna seems to share these views as BlueCross

BlueShield as well which is beyond great. Both corporations have their regulations on how to



operate and what services will be provided contingent to the implantation, which brings out the

potential of the implant. IDEA needs to understand these things and apply them.

A child, an adolescent or an adult with the implantation did not declare deafness upon

themselves nor want an implant for its aesthetics, because it is less than appealing to society and

within itself. The procedure is done because it is necessary for the individual to function in

society as normal as they possibly could. IDEA may not support the implantation because it

crosses ethical boundaries in their understanding, but it is also unethical to deny a child or an

individual services based on your own definition and ideals for discriminating between two or

more people and the way in which they are aided. The IDEA public law in comparison to the

other policies was in 2004, which is when people started to get used to the idea of cochlear

implants. This presents an older mindset in comparison to a policy that was made 10 and 11

years later with increased perspective with newer ideas and understanding.

I believe that the cost are concentrated to many people, but to a particular group as a

normal hearing child does not reap the benefits of a hard of hearing or deaf child or adult.

However the benefits on the other hand, I would say benefits both few and many people. It is few

people in the sense that as the child grows older they are exposed to a set amount of people or are

consistently around them, people within their network and a few others out of it. As that

individual gets older and become more a part of society and decide on their vocational choices,

then it affects many people because their job would require communicating with others, whether

their boss, patients, customers, co-workers, etc., communication becomes a bigger and more

demanding role. With the implantation the benefits would be greatly valued among everyone for

effective communication. The distribution of cochlear implants or the related services is also a

tricky one in the sense that thousands of people within the deaf society has received them, but in



comparison to the total population of the society and then of the world would be a fraction,

giving the impression of a few people.

Judicial Involvement

In the case, Carolina Care Plan Incorporated v. McKenzie, 551 U.S. 1176 (2006),

Carolyn the beneficiary of Carolina Care Plan Incorporated, has profound sensorineural hearing

loss in both of her ears, which makes the use of hearing aids useless in her regard. Due to the fact

that the plaintiff, Carolyn, could no longer benefit from an assistive hearing device, her doctor

advised her that cochlear implant was the only treatment in which would provide her with any

benefit in hearing signals again. Though this may have been the case, the defendant, Carolina

Care Plan Incorporated, denied her coverage for her medical necessity. The defendants abused

their discretion in terms of conflict of interest. Also, the insurance company used ambiguity in

their policies which they use to either stand for something or against it based on the situation

presented in front of them. In this case, it is the cochlear implants that would be costly to the

corporation. Therefore, the court found the administrator of this plan to be abusing their

discretion in denying the beneficiary coverage, but the court also “reversed the award of

attorney's fees” because there was no evidence of bad faith by the defendant when denying

coverage of the plaintiff.

In this court case, there seems to be a lot of ambiguity on the part of the administrators of

the Carolina Care Plan Incorporated, the defendants. The policy is written in a way in which one

statement could represent multiple views, leaving individuals to almost assume that the

ambiguity and in this case, Carolyn's cochlear implants coverage, is not there. In the defendants’

retort or reasoning for the denial of coverage, it was said that the cochlear implants are essential

assistive devices that simply amplifies sound, which means it is not necessarily medically



needed. What they failed to recognize is that though the cochlear implant may "amplify" sound,

it does not function in the way that the hearing aid would. The cochlear implant is an

"implantable prosthetic device" which has an inner and outer piece. The implant is surgically

implanted in the back of the ear in the mastoid bone, providing a new pathway to the cochlea,

which is much more convenient. This implantation allows for sounds to be coded and replicated

electronically, therefore it cannot assist or amplify sound, but it provides new means to hearing

sounds.

The court found that the defendant's argument did not match up to their own

interpretation of the policies they wrote, which leads me to believe they did not want to cover a

case with cochlear implants, though they tried to not do so indirectly. There may not have been

any personal vendetta against the plaintiff and the defendant, but large amount of money would

have to be provided for a single patient, instead of multiple individuals. This could have possibly

lead to the decision made, to not award coverage of her implant. The company was not acting in

bad faith, but I will assume that they were acting in their best interest, rather than in the best

interest of the beneficiary. They should re-evaluate their obligation and what their policies are

and to act within the patient’s best interest. They are in the business to help people live a healthy

and worrisome free life when they have health problems and not worrying if their insurance is

going to decide to cover them or not. Without the patients/ beneficiaries that insurance company

would not be in existence, therefore should act in accordance to what they are supposed to be

doing as an insurance company who needs beneficiaries in order to keep going.

This case is interesting in the way that it concentrates among a certain group of people,

people with hearing loss, but while that is, it is not extremely distributive. It is not distributive in

my understanding because it is not generalizable; changes from one person to the next due to the



ambiguous nature of the policy. Unlike the IDEA case that will be further looked into below, the

consistency or the transparency of the consistency present is not present. In terms of the cost I do

not believe it is distributive either, but is also concentrated on a much smaller group. It is

concentrated on a much smaller group because the group of people with this insurance policy

who has hearing loss and the amount of people who gets the cochlea implant, contingent with the

total population of hearing impaired or the hard of hearing is small allowing for a small cost.

The plaintiff in the case, Southern Tier Building Trades Benefit Plan v. Niedermaier, U.S.

(2014) Karl Niedermaier, has a history of hearing loss in both of his ears, bilateral hearing loss.

The plaintiff's benefit from hearing aid is less than functional and he needs his hearing

capability, given his job description, construction. He had requested twice the coverage for

cochlear implants and was denied both times before he went in and had his procedure performed.

He thought the denial was a misunderstanding, therefore proceeded with his procedure at the

University of Rochester Medical Center, in 2011. Not only was the cochlear implantation

coverage denied, but anything that was related to it was denied any coverage under the

disclaimer that anything artificial or hearing aids were not covered. In his view the plaintiff did

not classify a cochlear implant as artificial because there is nothing aesthetically appealing or in

other words beautiful about it as the implant has an exterior portion hanging off of your head,

unlike a breast implant which would be appealing overall.

The other is that pace makers which helps the patient live a somewhat comfortable life is

present and covered in the policy and not considered artificial, though they are man-made.

Before the surgery was performed, the insurance company was contacted according to the

plaintiff and the customer service technician told him that he was covered and that he did not

need any further follow-up. So the question is why would the cochlear implant that would help to



live a better life in terms of health and overall function like a pace maker, not be covered and is

considered to be artificial, but the pace maker is not considered artificial under the same

insurance definitions? Why would the customer assistant tell the patient that there was no needed

follow-up if they are all equipped with what is covered or have means to access such

information? For that reason, he assumed that there is a mistake in the plan or changes that were

not communicated properly.

The insurance company has a policy where anything that is artificially implanted within

the live body such as prosthetics which is “an artificial device that replaces a missing or injured

part of the body” according to the Merriam-Webster Dictionary, or a hearing aid among other

things would not be covered. Due to the fact that he was qualified for the health insurance by the

company and did receive it, he did not understand why he would be denied. He realizes that

something was going on and had asked his doctors to send notes along with definition and

classification that included distinguishing characteristics and features between a cochlear implant

and a hearing aid. The papers that were submitted explained the level of sophistication of the

product and that it is nothing like a hearing aid and is not a prosthetic because it does not replace

a bodily organ or function, but that provides a new path and along this path allows for the

stimulation of the 8th cranial nerve in the ear. Nonetheless, the courts did not weigh these

differences submitted by the doctors and nurses of the facility in Rochester, New York, where

the plaintiff performed his surgery. However, the court did place emphasis on the provided

information, but rather on definitions of what implantation mean and what artificial meant, thus

ruling out cochlear implant as a procedure is needed, hence supporting the technical definition of

an implantation which is insertion of an object into a living tissue.



The plaintiff could not provide supportive evidence of bad faith, irregularities and the

claim of plain language among others, therefore the case was denied. He could not provide any

proof, therefore he could not have a strong argument because all statements are now

unsupported, assumptions that are based upon personal feelings. In my opinion I believe that

there are inconsistences present in this case. One cannot classify and accept one implant as one

thing and deem another implant to not be. No matter what, the definition of what an implant is

still remain, which is implanting a foreign substance in different areas into a live tissue. So to go

on the argument that a cochlear implant is an implant and therefore not accept it and accept

others is a flawed reason and should have been overruled in the court because it does not add up

or follow the given logic. Also, not providing plain language in what is covered and what is not

is an important factor in this case. It provides too many ambiguity and allows for the patient to

make their own assumptions when that should not be the case.

Proclaiming that hearing aids are not covered, but by hearing aids you mean everything

that assist in hearing is not, but cochlear implant as stated earlier is not. You can only give aid to

something that has some level of function and need help to fully bring it through, but a cochlear

implant provides a completely new pathway to sound and its level of sophistication is beyond

that of any assistive hearing device. The language was not clear enough and needed to be

reviewed by the courts before they proceeded with the case. Given all the evidences/

assumptions that the plaintiff had or thought he had, they were not supported therefore had no

value. In this case, more should have been looked into, also given the fact that the insurance was

contacted before the implantation was done and was told that no prior follow-up on that was

necessary. Those are factors that needed to be looked into more because that is evidence of

inconsistency and probably neglect in the sense that, the information was not recorded properly

or the information was ignored.



It is imperative that in the future, occurrences such as this is minimized little to none.

There are many unfair opportunities like this case and the first case above where there are unfair

treatments being occurred when it comes to a certain disability. In this case, the disability is

hearing loss and the ‘aid’ or solution is cochlear implants due to the severity of one’s hearing

function. In my understanding and views of professionalism, treating someone unfairly just

because you did not want to cover them, for something they paid you for is illegal and

unprofessional. They invested time and money every week to provide that money that comes out

of their pay check, only to not get the care that they needed the most. It is also my understanding

that as the years progress and we get more technological and there are much more stimulus

coming in our environment whether through drugs, noise exposure or illness, the amount of

people with hearing loss is increasing. It is also my understanding that though one may not have

born with such disparity, it does not take more than a second or two to face the same issues with

the right stimulus. We are also moving forward into the future where technology is helping us to

solve certain illness that has been around for eons and had no solution and also a time where we

become more accepting of the people around us. One may not have the same solution to ideas,

but that does not mean it is okay to inhibit another person from a desired outcome. It is also

unethical to prevent someone to receive treatment for something that would improve their quality

of life.

In this case, like the previous one, it is not extremely distributive because the insurance

policy for that construction company is limited to only its workers and their family and is not

extended beyond that, which makes the effects of the effects of the court case concentrated

directly to that group of people covered. In construction, workers have increased risk of walking

away with some kind of illness or disability as they are exposed to more health risks. With the

outcome of the case, even though the defendant was not denied for having a pre-exiting



condition, he was facing issues with his pre-existing condition. His condition could possibly get

worst because of working in such a busy environment and for other workers, what difficulties

would they face with the insurance plan for medically needed procedures? The outcome is

something that could peek the alertness of other workers covered under the same insurance.

In the next case, discrimination is applied to the younger population of school aged

children. Services that are provided to children with disabilities are denying children with

cochlear implants services because they have an implant and not an inserted device much like the

first case that was looked at. Services are openly available to children who have hearing aids and

assistive listening devices, but as soon as cochlear implant comes in the picture, the benefits are

reduced especially one that is important for the child’s function in their most frequent

environment. This allows us to look into what exactly is the priority when these decisions are

being made and upon what criteria they are evaluated.

In this case, Petit v. United States Department of Education and Arne Duncan 675 F.3d

769; 400 U.S. 108 (2012), children with cochlear implants' parents who are aided by the

individuals with Disabilities Education Act (IDEA) services, challenged the department of

Education's Cochlear Implant mapping regulations due to the fact that their children had stopped

receiving said services. The mapping of the cochlear implant is the fine tuning of the device

based upon the exposure of different sound signals in the child’s environment. This makes

participation in an around school and at home, much better because a child better understands the

signals they are receiving. The mapping is the tuning of the electrodes in the cochlear implant,

which is arrayed in the cochlea. Each electrode adheres to certain level of sound/signal triggering

the nerves, allowing the brain to recognize what is being said or simply to pick up sounds from

the environment. By discontinuing the services rendered to the children, it puts those children, at



a disadvantage even more from basic levels. It also affects how much more that particular child

or children will be struggling in school, at home and in their community.

Audiology services regulation from 1983, was what Petit was fighting to enforce, which

includes mapping, among other functions are services that are related to cochlear implant or

perhaps even hearing aids. The IDEA'S "related services" definition is not necessarily favored

because it is ambiguous in the sense that you may think one thing is covered and another is not

and you may be completely off. This is similar to this issue that the court cases Southern Tier

Building Trades Benefit Plan v. Niedermaier, U.S. (2014) and Carolina Care Plan Incorporated

v. McKenzie, 551 U.S. 1176 (2006) are facing in the adult model. It does not have plain

language, therefore becomes a hard one to accept by parents when mapping in "related services"

regulation is dropped from the coverage. Under the education law, all children no matter their

level of cognitive or development, should not be discriminated against, therefore required to be

provided Free and Appropriate Public Education (FAPE) which is essentially special education

and its related services. Though FAPE is provided, related services does not render to providing

optimization and maintenance services for surgically implanted medical devices and cochlear

implants. People with cochlear implants are able to benefit from the provided services, but their

classification is not covered under the umbrella of related services.

I find that these problems have so many loop holes for being able to provide and a whole

other set of loop holes to go around providing appropriate services in order to not provide them.

While there are certain things like cochlear implants that are covered for children in most

insurance policies, there are still situations where those children who are of median income

households get left behind or slips through the cracks. If one does not have the finances to

provide a certain kind of aid that they know their child needs, the child easily gets forgotten and

lost in the system and essentially gets left behind due to not having the right supplements that



caters to their need. While certain accommodations are required like FAPE, others are not

enforced and while these special education children and other services may be just getting by.

These children are not stimulated enough or perhaps cared about enough to push them further

from coasting. The court denied the claims and gave the district court's grant summary judgment

to the Department. In the case it states that all of the “uncertainty is legally irrelevant” and this is

the case because IDEA has been consistent with cochlear implant mapping exclusion. But while

they are being consistent with what they rather deal with, as I mentioned earlier in the second

case, it is unethical to deny someone services that would increase their quality of life lived. So

then what role is the ethics committee playing in these decisions that are being made?

The effects of this outcome affects a large amount of individuals because there are a lot

of children covered under IDEA for disabilities as it not only govern one state, but it regulates all

children in the United States because it is a federal law. The concentration however, is even

much smaller because not a lot of children in comparison to the deaf population gets cochlear

implants though it may be recommended for them and as a result the potential cost is lowered

and is redistributed to other areas that are more appropriate according to their regulations.

What I found to stand out among all three court cases is that they all have a level of

ambiguity when it comes to providing services for the people who need them and services that

are supposed to be rendered to them. Words that are essentially interchangeable have different

meanings depending on their context which inherently changes the interpretation. This may not

work in one’s favor when services are already rendered and coverage needs to take place, leading

to a court case as is above. Why does it takes so much out of insurance or government policies to

make a positive effort to aid someone the way they would if one of their family members were to

be in that position? Courts allow the bare minimum that these corporations provide and turn a



blind eye to the things that are important, essentially affecting the recipients of the decreased

services. In these cases, individuals with hearing impediments hinders everyday function

whether at school, work or otherwise and may need their hearing, except maybe when sleeping.

Our ears are extremely important parts of our body, both inside and out. The fluid in our ears

even controls our balance and just a slight illness could throw that off balance enough to give

you vertigo or worst. Imagine living that life every day without the appropriate help, it would not

be a healthy physically, emotionally, or mentally. Both the court system and how the insurance

corporations’ approach disability, need to modify their ways of thinking because health does not

affect one person, but it affects everyone around that individual. People with hearing loss already

have much counting against them; negative results from court cases for unfair treatments should

not be one of them.

Why are all of these cases important? They are important because it reflects the unfair

treatment that people of hearing disability with cochlear implants face. They have been facing

unfair advantages for many years and they will have more to come, but hopefully the amount is

reduced. With this policy analysis, it is the hope that all the points are taken into consideration

and necessary adjustments are taken to create much of a chance for individuals who are facing

hardship because of their disability and to reduce the ambiguities in these issues.

Ethics

According to the Merriam Webster Dictionary, Distribution Justice means “the justice

that is concerned with the apportionment of privileges, duties, and goods in consonance with the

merits of the individual and in the best interest of society”. With that being said, there are

instances where there are services are not appropriated equal among individuals do to

discrimination of the approach one takes to solve their health related issues that may not matchup



with their own. Whether through the Individuals with Disability Educational Act, Health policies

or cases involved in judicial reviews, there are some levels of discrimination among individuals

that affects the justice in distribution which ends up affecting the health of the individual.

Fiduciary responsibility is a legal duty to act solely in another party's interest. With that

being said, insurance companies have an obligation owed to the beneficiaries or principals. The

principals invested their hard working money and time making the money to put into their health

insurance policy. It is rather the insurance company or the fiduciaries' responsibility to bring

forth what was promised in the first place. It is a fraudulent act to promise a service and not bring

it through especially when money and people's lives are involved. It is a fiduciary responsibility

for insurance corporations to follow through on services. Beneficiaries or principals put money

in to gain something back in the future when they need it the most. Based on all the policies and

judicial reviews that is in this analysis, most of them needs to be looked over more precisely.

Without having morals, the way that one operates themselves and their business is highly

affected in the sense that it is projected towards the beneficiaries when navigating. Ethics is the

rules of conduct that are recognized by individuals in respect of each other and is externalize

because it is based on a social system or structure. On the other hand, moral is the principle or

habit with respect to the conduct of right or wrong; it is one's own internal navigation system

which tells them whether an act is right or wrong. Without having an internal conscience

reminding us of the things we do and how it affect other people influences the way one operates

overall. In the Public Law 108-446, for the Individuals with Disability Education Act, there are

services for children who have disabilities. It is a law to provide disadvantaged children with

access which helps them to achieve in school with as limitation to them as possible. In terms of

hearing loss, services are rendered to children with hearing aids and other assistive devices along



with Audiological services. They have services that helps them to do well in school in the

appropriate manner. These services however, are not applicable to children who have such a

severe level of hearing that they need cochlear implants to provide a new pathway for hearing for

them. These services are not denied because they believe that the child will not benefit from the

implant because they are practically deaf and would probably not receive much of help, but they

are denied under the reasoning that they are wearing an implantation. With the law being in place

to provide all children with little to no limitation in their advancement, is it ethically right to

deny these children who need, not want the services, the right that was given to them by the law?

Isn't denying the children viable services to help them improve their communication not only in

school, but in and around their community limiting their advancement, which is the complete

opposite of their mission and immoral? If your mission is preparing students in underserved

communities for success in college and citizenship along with a vision of ensuring that all

children reach their potential, where does that leave children with cochlear implants? Aren't they

underserved and underrepresented as well? If the people, programs, laws or statutes that are in

place to help, are not helping, where does the people who are left behind stand? What morals do

these people who are denying the services have and what do they stand for?

In the Excellus BlueCross BlueShield Medical policy, they have a policy set in place for

people have not only hearing loss, but individuals who have cochlear implants also have the

opportunity for an increased quality of life lived. Aetna Clinical Policy Bulletin on Cochlear

Implants and Auditory Brainstem Implants also have accommodations for people with implants.

Both of these insurance corporations are among the few that have relevant help. Their intentions

on helping people with the disabilities under the umbrella of hearing are of prime morality. They

understand that to get a cochlear implant is a medical necessity that does not make them less than

or more than anyone else. The coverage that is provided is not only beneficial, not at the lowest



care possible, but they also provide follow-up services where the principals can receive 6-10

sessions of speech reading among other services which approximately 25 hours. With this and

related services, the principals are able to maximize their potential in the aids. These companies

provide the level of transparency where there is no room to doubt what is covered. There is no

second guessing where the principals are confused as to whether or not they are covered due to

ambiguity because all of the accommodations are clearly stated. With models like these two

insurance, you gain trust, loyalty, and honesty from your benefactor. There should be a level of

transparency that is presented throughout all these policies and judicial reviews, but instead they

are mostly filled with ambiguities. These ambiguities leads to a lot of misunderstanding between

the fiduciaries and the principals. The principals assumes that they are covered for certain

medical issues because the fiduciaries did not clearly state that they did not. This greatly affects

the relationship between the two because there should be a level of trust and understanding

among them. Patients expect to be covered for their medical issues, they have insurance policy

for a reason.

Instilling a level of trust through having integrity in your business affects the way how

people react. Without having transcendent morals as I mentioned before, the way in which you

operate is affected immensely because your behavior is projected and carried out through you,

what your business represent and what your staff is doing. If your employees are projecting

services that does not support transcendent morals then the trust that was or is instilled will be

affected. No one wants to work hard and then willingly hand over their wages to not receive

anything from what they invested in whether for a short period of time or over the period of

many years. Transcendent



Through the Southern Tier Building Trade Benefit Plan v. Niedermaier case, Karl

Niedermaier is a construction worker who has been struggling with his hearing for most of his

life. Niedermaier received his insurance through the construction company he works for and

because he has had problems with his ear his entire life, he assumed along with his doctors that

he would be readily covered by his insurance as his defect was not a secret. His plan did not

clearly state that cochlear implants are not part of his coverage and that would have been

something that he would have made a conscientious choice on given his history. Under the term

that was provided such as implants or hearing aids he did not feel was applicable to him as some

implants such as stents and pace makers are covered and hearing aids are not covered as well.

Anything prosthetic or hearing related were not covered, but he found that out after he already

had his surgery. Pre-surgery he was told that he was covered and needed not to follow-up on the

call. That means that the way the policy is written was confusing enough for the customer

assistant to interpret something different from what is actually meant. Niedermaier ended up

losing the case, because there was no evidence of bad faith against him. Doing business like this

messes up one's reputation. Due to misunderstandings because of the ambiguities, he was led on

to believe that he was in fact covered when he was not and left with a bill that he has to pay.

If there was fair judgement in the case, then a lot of the misunderstanding that took place

would not have taken place at all, but without having a transcendent morality, there will not be a

time where one considers a limitation on what is fair and what is not because it is an almost

foreign idea. A sense of right or wrong navigates an individual to make choices that not only

yield a one way benefit, where only the fiduciaries gain and the principals lose, but to also take

into account the investment that has been made through them. By this both will gain what they

want from each other yielding a win-win circumstance. Businesses today do anything to gain

money, including dishonoring people who help to get them where they want to be in the world of



business. One would think that because insurance companies, policies and judicial cases would

have a different approach in morality when it comes to health related issues, but it clearly makes

no difference as a change of moral would affect their income. Medical providers and everyone

who is associated with making health in each individual, should be in the business of putting

themselves out of business. They should not be in the business of capitalizing off of other

peoples' health concerns or problems.

I believe that having some degree of morality affects how you approach and look at

things. As I mentioned before that morals are your navigation system, it is your guide in the back

of your mind and one that also triggers a certain emotional reaction when you do things that is

positive or negative. That is generally associated with having transcendent morals and bad

morals. If you do something that you know you should not have done, not only because you were

told it is wrong, but when you do it, it triggers not only a saddened demeanor, but it also triggers

guilt as well. In the world of business, people are taught to bury their emotional attachment to

things that are right from wrong because it also plays into making money versus not making

money. After a while of burying personal beliefs for the way a business works people tend to get

carried away with the things they do to others because their navigation system became broken or

they simply unplugged it since they were not taking the route that it is provided. Without our

morals, we get caught up in many things and these may not be as prime as we thought, even if

the revenue is much because at the end, we may end up losing a part of ourselves for the

business.

Options Cost Effectiveness Incremental Total Status Quo

*No change

4 3 N/A 7



*1-5 – low to high cost, effectiveness, and little incremental to a lot

Criteria Analysis

My goal with this chart is to show all the different solution possibilities of the policy

analysis. The above chart have four distinguishingly different solution to the problem. Some of

the solution is more likely than others while some is more realistic than others. With the goal in

mind to have less ambiguities in the health policies and more fairness in the practices. With that

in mind the four solution aims to combat the issue at hand with three common factors that are

held in all four solutions, which are cost, effectiveness and incremental.

Status Quo

The status quo currently in the small corporations is to deny people with cochlear

implants using ambiguities in their policies. Ambiguities would remain and the corporations like

BlueCross BlueShield would continue to run their business their way and likewise for the smaller

corporations. To keep the status quo means to have regulations remain just the way they are

without any changes made. In the chart it is given a rank of 4 because its current state is costly to

who needs cochlear implants. The overall cost for an implant is expensive and if insurance

companies fail to provide coverage, the patients/benefactors will pay approximately $60-100,000

without any help. It is not a 5 because cochlear implants and related services are not as expensive

Incremental Government

Solution

*Implement Rule

5

4 5 14

Private Industry Solution

*Capping

3 5 4 12

The crazy "unique" alternative

*unlimited Coverage

N/A 5 3 8



as a cancer treatment plan. The effectiveness is a 3 because of its level of feasibility. It is

possibly to keep this state because it only affects a specific set of people and not the general

population of the people that the particular insurance covers. The feasibility is also in question

because the status quo is the reason why the policy analysis is created in the first place because it

is not working for the people who are directly affected. This will take no time to get started or

implemented because nothing will be changed.

Government Solution

The government could implement a rule where insurance companies directly states what

they cover and do not cover in order for there to be no confusion between the beneficiaries and

the policies; noncompliance results in a fine. The government solution is a particularly intriguing

perspective where it has the potential of becoming a political matter. This is also particularly

intriguing because of the perspective of people living in the United States where the political

decisions are based upon the people, and the people opposes the idea of the government

involvement in matters that affect them in regards to their own health. Even so, implementing a

rule that affects the insurance companies and the way that they operate may be a feasible deal

that could work for benefactors all around or in specific areas where common complications are

present. In terms of cost, it has the highest rank of 5 because it would be rather costly to the

companies who does not already have appropriate accommodations for cochlear implants and

related services. This would cost the smaller companies more money than the larger companies

because the smaller companies have more ambiguities as a mechanism to control their budget. In

the bigger companies, they essentially have more money, but they would need less changes made

because they already have lesser ambiguities.

By fining the companies if they refuse to comply and continue to deceive their

benefactors, it would give them the push into the right direction. No one likes to be charged for



doing anything no matter how much the fine is, because it is the violation of the principle behind

it that creates an emotionally reaction. By being fined, they are put at risk for gaining more

people to invest in them with negative reputation. This would be effective because it would force

companies to start making better choices and the consumers to start making educated decisions.

This would take about 3 years to reach its full effect because of judicial reviews and approval.

This may be feasible in part, but with the involvement of the government may make the process

harder than just suggesting a change to the system.

Private Industry

In private companies, they could allot a certain amount of coverages per year and after

they reach a certain amount of people then the money distributed in that area is capped. The

private industry solution is to create a cap on how many people per year a particular insurance

company would be able to handle each year based upon its size and budge. By creating a cap,

you allow for serious considerations to take place in how you will allocate the resources and it

also prevents you from going over budget and providing for something that your company

cannot afford, this earns them a cost ranking of 3. This creates the problem of discrimination

among the beneficiaries, which is part of the problem we are trying to solve. Nonetheless, this

would be a possible and realistic solution.

If every insurance corporation should put a cap for 2 cochlear implants, they already

outnumbered the target number of 100 for everyone in 2010. There are over 1,000 health

insurance companies controlled by a few larger corporations. By doing this you provide access

and in this case you are not keeping away coverage intentionally, but it is a matter of finding an

insurance policy that you are one of the two that may need cochlear implantation or related

services taken care of. I believe that this would be able to be done because insurance companies

providing for more than five is losing a lot of money, but the companies that denies it would not



be happy with having to provide for 5 people if the need ever comes up in a given year. I think

that this could be in full effect in approximately a year and half after all the needed work is

sorted through, proofed and marked for approval.

The crazy “unique” alternative

This option provides coverage for people in all levels of hearing loss who needs or wants

cochlear implants because they think it would be better for them along with all related services

provided without any confusions or discrimination from any of the parties. The unique case of

providing coverage for everyone with money not being a barrier to any kind of treatment does

not have any ranking for the cost as there is no minimum or maximum limit for spending. There

are not millions of people who are demanding to receive cochlear implants, so after the initial

rush of people getting the procedure done, the demand may increase though the option may still

be present. In a sense this solution is effective because it would effectively wipe out the need,

but it could also be deemed ineffective after a while. After the initial rush people may stop taking

advantage of their opportunity because they did not have to work for it. With this they may not

explore the full potential of the device because they did not work hard for it nor appreciate the

value of it. This is an unlikely to happen situation however attainable it is. This would take no

time at all to implement because there would not be much logistics to work out except possibly

the legality and the distribution and how it would be distributed, maybe.

Recommendation

I would recommend the private industry solution because it seems feasible for the most

part. It seems to be a logical step, a step that the administrators, the representatives and the

beneficiaries could learn to agree on and appreciate. It seems like a strong recommendation

because it would create an opening but also a limit of that opening. It would be beneficial

because:



2 x 1000 = 2000 2000/100 = 20 – number of possibilities of finding a coverage for each person

This way everyone would have the potential of having a secured health insurance plans to cover

for their illness. The unique solution does not work because it is wishful thinking and is unlikely

to happen. Staying the same does not make sense because that is the reason the policy is being

drafted in the first place. The other solution that could possibly work if the private industry fails

would have to be the government solution because it indirectly forces everyone to make almost

honest and transparent decisions. It is almost honest because there is always a way to get through

seemingly tightly sealed decisions. These two possibilities are likely, but as I said I would

recommend the private solution, not only because it is the one that seems to work best, but

because it does not have that government factor that many people hate to have when making

decisions on their health.

To conclude, making these criteria and trying to show what the possible solutions are

takes a little work, but it is not too complex. The complexity comes in when you find that the

chart may have another solution to your issue at hand, different from what you was anticipating.

This challenges your perspective because now you have to fight to prove that what you are

suggesting is the one that will work the best. In this case Private Solution is not the easiest choice

and rather, leaving the policy as is, is in fact the easier choice. Nonetheless, there as a reason

why the policy analysis was drafted in the first place and I would strongly recommend the

private company solution because it provides a standard that everyone has to meet which is

allotting a certain amount of coverage per year for every insurance companies. This is a feasible

solution because 1. The amount of coverage total would outnumber the amount of people who

are in need of coverage for cochlear implants. This would also be like a gamble, due to the fact

that only 2 coverages per year is allotted, it does not mean that your company will be the one

who have the patients that need the Audiological services associated with cochlear implants.



With this standard, you either pay for the people who needs it with a cap of two or you

completely save your money without losing anything for that year. This would be a feasible

solution because then, no one can say that there is no appropriate accommodations, because the

insurance companies would have that accommodation in place by default whether the

beneficiaries knows of it or not and whether or not they use it. This would also play in the

insurance defense if there should be any matter being brought up. Obviously it would have to be

carefully planned out, but if it is important, no one will delay it too long and everyone would

receive their services. I also do believe that this solution to the ambiguities presented with

insurance policies and judicial cases would be accepted by the American Speech-Language

Hearing Association.

Bibliography DEMOGRAPHIC ASPECTS OF HEARING IMPAIRMENT: QUESTIONS AND ANSWERS

Third Edition, 1994." Demographic Aspects of Hearing Impairment. Gallaudet

University, 1994. Web. 09 Feb. 2015."

Harrington, Tom. "Deaf Statistics Tags: Deaf, Faq " Deaf Population of the U.S. Gallaudet

University Library, Feb. 2014. Web. 09 Feb. 2015.

"United States Census Bureau." Income, Poverty and Health Insurance Coverage in the United

States: 2011. N.p., n.d. Web. 09 Feb. 2015.

"Quick Statistics." [NIDCD Health Information]. N.p., n.d. Web. 08 Feb. 2015.

"Cochlear Implants." Cochlear Implants. N.p., n.d. Web. 01 Feb. 2015.

"Cochlear Implants." American Academy of Otolaryngology-Head and Neck Surgery. N.p., 21

Apr. 2014. Web. 09 Feb. 2015.

"Charts and Tables." [NIDCD Health Information]. National Institute of Health, 30 Sept. 2014.

Web. 04 Mar. 2015. <http://www.nidcd.nih.gov/health/statistics/Pages/charts.aspx>.

"The Prevalence and Incidence of Hearing Loss in Children." The Prevalence and Incidence of

Hearing Loss in Children. American Speech-Language Hearing Association, n.d. Web.

04 Mar. 2015. http://www.asha.org/public/hearing/Prevalence-and-Incidence-of-Hearing-

Loss-in-Children/

Individuals with Disabilities Act of 2004, Pub. L. 108-446, 108 stat 2647

Excellus BlueCross BlueShield Medical Policy, § 7.01.26 (2014)

http://www.asha.org/public/hearing/Prevalence-and-Incidence-of-Hearing-Loss-in-Children/

http://www.asha.org/public/hearing/Prevalence-and-Incidence-of-Hearing-Loss-in-Children/



Aetna Clinical Policy Bulletin: Cochlear Implants and Auditory Brainstem Implants § 0013

(2015)

Carolina Care Plan Incorporated v. McKenzie, 551 U.S. 1176 (2006)

Southern Tier Building Trades Benefit Plan v. Niedermaier, U.S. (2014)

Petit v. United States Department of Education and Arne Duncan 675 F.3d 769; 400 U.S. 108

(2012)

legal final paper

Documents

topic of cochlear implants

distribution of services

corporate policies

health issues

health service corporations

terms of distribution

distribution of resources

degree of hearing loss