Hypothyroidism denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: a 57-year-old female with diagnoses of menopausal and female climacteric states, and hypothyroidism. Findings: The physician reviewer found that the patient has a family history of ovarian and breast cancers. The patient had a pelvic ultrasound in 2015, which revealed an intact uterus and intact ovaries. Her most recent thyroid stimulating hormone (TSH) was performed in December 2018, and was suppressed at 0.02. The treatment plan included levothyroxine 125mcg daily and Cytomel 25mcg daily. Additional medications have included T4/T3, estrogen, progesterone, dehydroepiandrosterone (DHEA), testosterone, and growth hormone therapies.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for compound thyroid cream with a combination of T3 and T4. Thyroid hormone therapy as an initial full replacement or as partial replacement with gradual increments in the dose titrated upward using serum thyrotropin is the goal of treatment in patients with hypothyroidism. Providers make dose adjustments when there are large changes in body weight, with aging, and with pregnancy, with thyrotropin assessment four to six weeks after any dosage change. A substantial number of studies on patients with TSH levels between 2.5 and 4.5 have reported beneficial response in atherosclerosis risk factors such as atherogenic lipids, impaired endothelial function, and intima media thickness.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing services [F5 (coagulation factor V) (e.g. hereditary hypercoagulability) gene analysis, Leiden variant; F2 (prothrombin, coagulation factor II) (e.g. hereditary hypercoagulability) gene analysis, 20210G>A variant; and MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g. hereditary hypercoagulability) gene analysis, common variants (e.g. 677T, 1298C)]. There is a lack of evidence to support the use of the services at issue for the diagnosis or management of hypothyroidism or low testosterone. Genetic testing is not part of the diagnosis or treatment of hypothyroidism or low testosterone.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Nature Throid. The patient is a 57-year-old female. At an office visit, lab results showed she tested positive for thyroid antibodies, which her provider believed was due to episodic thyroid underactivity. During the visit, the patient indicated she wished to start natural thyroid hormones. She has been taking Nature Throid. The enrollee indicated her dosage has increased over a two-year period to 97.5mg. A lab report revealed her thyroid stimulating hormone was 0.39 (reference range 0.45 to 4.12) and thyroid peroxidase antibodies were 40 (reference range less than 35). A later report showed a T3 level of 2.2 (reference range 4.6 to 11.2) and thyroid peroxidase antibodies of 40.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving hypothyroidism, then check the rights and deadlines that apply to your plan.