Growth Hormone Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a nine-year-old female with a long history of growth delay. She has been diagnosed with Noonan’s syndrome. She has been treated with growth hormone therapy since September 2003 with marked improvement in her growth, and her physician has recommended further treatment with growth hormone therapy. The Health Plan has denied authorization and coverage for growth hormone therapy on the basis it is considered experimental for treatment of the patient’s medical condition. Most academic centers in the United States use growth hormone for treatment of patients with Noonan’s syndrome. In the case of this patient, there is potential for ultimate short stature. The patient has had a very positive response to initial growth hormone therapy. Use of growth hormone for treatment of patients such as this patient is standard of care in the national community.

The patient is an 11-year-old male who has a diagnosis of idiopathic short stature. He had a growth hormone stimulation test in November 2004, which had a normal response. A radiologic report found the patient had a bone age reading of 8 years at the chronologic age of 10 years 8 months. The consulting pediatric endocrinologist indicated the patient had a bone age of 9 years and 6 months at the chronologic age of 10 years 1 month. By calculating the patient’s predicted adult height based on each x-ray reading using Greulich & Pyle’s Radiographic Atlas of Skeletal Development of the Hand and Wrist, the respective final height predictions differ by less than 2 inches, (65 inches using a bone age of 9 years 6 months and 66 inches using a bone age of 8 years 10 months). The patient began receiving growth hormone therapy in February 2005.

Where the denial was upheld

The patient is a 14-year-old male who has been diagnosed with neurosecretory defect or functional growth hormone deficiency. He has continued to drop percentages over several years from the 25th percentile to the 10th percentile with his growth velocity below the 3rd percentile for his age and gender. His parents report that based on observations over a 15-month period in addition to a low IGF-1 level and IGFBP3 level, his physician indicates the patient’s height percentiles will continue to drop. Therefore, growth hormone therapy has been recommended. The Health Plan has determined growth hormone therapy is not medically necessary for treatment of the patient’s medical condition.This patient was seen for short stature by a pediatric endocrinologist in December 2003.

This patient is a 37-year-old male who was evaluated in October 2004. He presents with symptoms of fatigue, decreased libido, inability to lose weight, joint pain and difficulty concentrating. The patient was felt to have hypogonadism. His baseline testosterone level in November 2004 was 284 (350-1030); free testosterone 58 (52-280); percent free testosterone (dialysis) 2.2% (1.5-3.2%); sex hormone binding globulin 0.2 (0.5-1.5); and LH-level 3.6 (1.5-9). He has been treated with Androgel 1% since the initial evaluation. Several subsequent testosterone evaluations have been performed and there has been no marked increase despite treatment with Androgel. The percent free testosterone levels remained normal and the sex hormone binding globulin remained low.

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 Growth Hormone Therapy, then check the rights and deadlines that apply to your plan.