Adult Growth Hormone Deficiency: when insurers say no, reviewers often say yes

Where the denial was overturned

A 19-year-old male enrollee has requested growth hormone therapy (Genotropin) for the treatment of his Prader Willi Syndrome (PWS) and adult growth hormone deficiency. Findings: Two physician reviewers found that while growth hormone (GH) tests may not be as useful in PWS as in other disorders because of the confounding effect of obesity in these individuals, the use of GH therapy is well established. As noted in the references, there is evidence that GH is an approved therapy to maximize stature in patients with PWS. The records provided for review show no evidence that this patient’s growth plates have closed which lends even more support to the contention that he is likely to benefit from GH therapy. All told, the use of growth hormone therapy for treatment of patients with PWS is a medically appropriate indication, and the patient is an appropriate candidate for continued therapy.

Where the denial was upheld

This 53-year-old woman with multiple medical problems requests growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms and the response to an arginine/GHRH stimulation test. She has obesity with progressive weight gain and depression treated with Lexapro. She complains of muscle pain and weakness, poor sleep, fatigue, poor concentration, and decreased libido. She is post-menopausal and on large doses of thyroxine for presumed hypothyroidism.The evaluation by her endocrinologist revealed a normal MRI of the pituitary. An arginine/GHRH stimulation test revealed a normal peak GH of 11 ng/ml. She has a suppressed TSH presumably due to the large dose of thyroxine and has an elevated LH and FSH, a normal pituitary response to inadequate estrogen replacement in menopausal patients.There is no evidence of AGHD in this patient.

The patient is a 45-year-old woman purported to have a primary hypogammaglobulinemia and adult growth hormone deficiency (AGHD). The patient reports fatigue, malaise, lethargy, cognitive deficits, and a history of thrush and other body sores. Two Candida species grew in a sputum culture dated 6/17/04. A workup for the hypogammaglobulinemia has not been submitted but the patient is said to have mannose-binding globulin deficiency. There are no immunoglobulin or T cell CD 4+/CD8+ ratios to suggest a mannose-binding lectin defect. It appears the patient has been receiving IV gammaglobulin. A multitude of laboratory tests have been submitted including a series of growth hormones dated 11/12/03, which appear to represent some sort of stimulation test.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for adult growth hormone deficiency was denied, the published record says the denial is worth fighting.