Idiopathic Short Stature denials in California external review
In the California DMHC record, independent physician reviewers decided 235 published external-review cases involving idiopathic short statureand overturned the plan’s denial in 46.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for idiopathic short stature
| Treatment | Decisions | Overturned |
|---|---|---|
| Nutropin Aq Nuspin | 40 | 40% |
| Genotropin | 40 | 42.5% |
| Growth Hormone Therapy | 29 | 79.3% |
| Omnitrope | 22 | 54.5% |
| Humatrope | 18 | 44.4% |
| Nutropin | 15 | 46.7% |
| Norditropin Flexpro | 13 | 69.2% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 229 | 47.2% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 6 | 16.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for the medication, Norditropin Flexpro. The enrollee has severe short stature, poor growth velocity and a three-year delay in bone maturation. The pediatric endocrinology office note indicates the enrollee’s magnetic resonance imaging (MRI) revealed a seven millimeter anterior intrasellar lesion. Pituitary function testing was performed twice and was normal. Neurosurgery recommended a follow-up MRI in six to eight weeks. The plan was to start growth hormone (GH) if the lesion was stable. The repeat MRI showed no change. The enrollee’s height was documented as 112.5 centimeters; less than the first percentile, and her weight was 23.8 kg, placing her in the 13th percentile. Her bone age was five years, nine months at a chronological age of eight years, seven months.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Nutropin pen-injector. Growth hormone (GH) therapy has been shown to be effective in improving the final adult height in pediatric patients diagnosed with idiopathic short stature (ISS). ISS is defined as a height below -2 standard deviations (SD) on a growth curve that correlates with age and sex. The U.S. Food and Drug Administration (FDA) has approved GH therapy for the treatment of pediatric patients with ISS. Treatment with GH therapy is indicated for patients with ISS who are shorter than -2.25 SD, have open growth plates, and have no other underlying condition. Notably, GH therapy has been shown to be beneficial in the final height outcome of pediatric patients with ISS, even when treatment is started late.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The provider requested authorization and coverage for Nutropin AQ Nuspin 20 solution pen for the treatment of idiopathic short stature (ISS).Growth hormone (GH) therapy has been shown to be effective in improving the final adult height in children with idiopathic short stature (ISS). The U.S. Food and Drug Administration (FDA) approved GH therapy treatment for the treatment of ISS in 2003. The National Institutes of Health defines ISS as a height below – 2 standard deviations (SD) on a growth curve that correlates with age and sex. Treatment with growth hormone has been approved for ISS children shorter than the – 2.25 SD who have open growth plates and no other underlying condition.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parents of the patient requested authorization and coverage for Nutropin AQ.Growth hormone (GH) therapy has been shown to be effective in improving the final adult height in children with idiopathic short stature (ISS). The U.S. Food and Drug Administration (FDA) approved GH therapy treatment for the treatment of ISS in 2003. The National Institutes of Health defines ISS as a height below – 2 standard deviations (SD) on a growth curve that correlates with age and sex. Treatment with growth hormone has been approved for ISS children shorter than the – 2.25 SD who have open growth plates and no other underlying condition. The response to GH is variable, and the predicted height is not an absolute criterion for growth hormone treatment decisions.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 idiopathic short stature, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY