Hormones denials: what the review data shows

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.

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.

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.

Physician 1: The patient is a 36-year-old female with twin gestation. She was noted to have cervical shortening (without dilation) and her provider has recommended 17 alpha-hydroxyprogesterone caproate (17P) injections to decrease the chance of a preterm delivery. The patient’s request for authorization was denied by the Health Plan based upon a determination that 17P therapy is experimental/investigational.The 2003 ACOG committee opinion cited above specifically recommends against the use of 17P in patients with multiple gestations and no history of prior preterm birth. Although there are currently placebo-controlled studies investigating the use of 17P with twin and triplet pregnancies, the results are not yet in. We do not have sufficient safety data to support the application of 17P therapy with twin gestation.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Hormoneswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.