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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AndroGel gel packet for treatment of the enrollee’s hypogonadism. Findings: The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Fatigue, lack of concentration, reduced muscle and bone mass, and weight gain are symptoms of male hypogonadism. Abadilla, and Dobs in their review of topical testosterone supplementation for treatment of male hypogonadism noted, “Topical/transdermal testosterone replacement therapy, including patches and gels, are the most modern formulations on the market. These treatment options have been known to yield more physiological concentrations of testosterone.

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the hormone implants (CPT codes 11980 and J3490). Low testosterone can lead to such complications as reduced libido and erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood, and fatigue (Dandona and Rosenberg). For these reasons, current data supports treatment of patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). While topical gels and intramuscular injections are the most commonly prescribed formulations for testosterone replacement therapy, the short half-life of testosterone may be problematic for some patients. These modalities can often lead to highly variable levels of testosterone, resulting in poor patient compliance.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hormone implants for treatment of the enrollee’s menopausal symptoms. The 3 physician reviewer found menopausal management is a complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and/or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. Some of these more traditional therapies may include, exercise, weight loss, topical lubricants and moisturizers, topical estrogens, stress reduction, biofeedback, counseling, and serotonin reuptake drugs.

The case involves a 12-year old male who has been diagnosed with idiopathic short stature and for whom growth hormone (GH) therapy had been prescribed over the previous year with an excellent growth response. A two-point growth chart indicated that the patient’s height was -2.25 standard deviations (SD) below the mean and in the 3rd percentile at age 11. A physician’s note indicated a height response of 3.25” in 11 months of GH therapy through April 2005. The notes were largely handwritten with limited detailed information. Nevertheless, the parents were 6’ and 5’6” tall giving a mid-parental height potential or target height of 71”. A predicted final adult height based upon data from 9/01 was given as 5’3. 6”.

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 hormone deficiency was denied, the published record says the denial is worth fighting.