Develop Delay Ortho: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that The patient’s parent has requested authorization and coverage for in-home speech therapy and/or additional one-hour sessions per week of occupational therapy (two one-hour sessions per week total). Per the American Academy of Pediatrics (AAP), there is a clinical role for the treatment of pediatric patients with autism spectrum disorder utilizing medical home care services. The authors concluded that, “Inadequate medical home care yielded higher odds of current educational service use.” In addition, another study found that having medical services provided within the home has been associated with lower odds of difficulty getting needed mental health care as well as non-mental specialty care. With regard to this patient with autism, the requested in-home speech therapy services are indicated and consistent with the AAP recommendations.

The parent of an enrollee has requested authorization and coverage for Kallmann Syndrome panel genetic testing.Findings: Three of three physician reviewers found that there is sufficient support for the requested services in this clinical setting. Many underlying conditions can lead to primary amenorrhea in young women. Typically, the diagnosis of Kallmann Syndrome is suspected by the pediatrician and made by a pediatric/adult endocrinologist. As this is a genetic condition, testing for the various different genetic forms of this disease may also assist in making the diagnosis. From the pediatric endocrinologist perspective, an accurate diagnosis needs to be obtained. Clinical presentations similar to Kallmann Syndrome can occur from other causes disease process.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Genotropin injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s Idiopathic Short Stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin for treatment of his short stature. Findings: The physician reviewer found that the records provided for review do not support the medical necessity of the requested Nutropin AQ NuSpin for treatment of this patient’s short stature. Specifically, there are no growth curve and no statement as to the patient’s genetic target. This is important because the bone age determination suggests the adult predicted height is around 66 to 67 inches and the bone age is not delayed. In patients with GH deficiency, the bone age is characteristically quite delayed. That is a prediction based on a bone age of 13 years at a chronologic age of 14 years 2 months.

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 develop delay ortho was denied, the published record says the denial is worth fighting.