Nutropin Aq Nuspin denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s short stature. The submitted documentation supports the medical necessity of the requested medication. Based on the specific medical needs of the patient, current literature and published guidelines, this patient would benefit from growth hormone treatment for the diagnosis of idiopathic short stature for the following four reasons. First, this patient has clearly abnormal growth velocity as indicated by the growth chart, which was always growing below the third percentile. Second, the patient had a bone age, which gave an estimated adult height of 147 cm. This is an extremely low adult height.

Nature of Statutory Criteria/Case Summary: The patient with a history of short stature. The patient’s height is less than 2 standard deviations (SDs) below the normal range for age and gender, and she is noted to have poor growth velocity. A prescription drug form reported the patient is consistently below the first percentile at -2.27 SDs below the mean. The provider has recommended treatment with growth hormone therapy. At issue in this case is whether Nutropin AQ NuSpin is medically necessary for treatment of this patient.The submitted documentation supports the medical necessity of the requested medication. Idiopathic short stature (ISS) is defined by a height below -2 SDs below the mean without findings of disease or pathology that can explain short stature. Growth hormone is approved by the U.S.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting authorization and coverage for the medication, Nutropin AQ NuSpin. The enrollee has type 1 diabetes mellitus and poor growth. His growth velocity is below normal. His current height places him in the tenth percentile. His endocrinologist placed him on growth hormone (GH) therapy and indicates the enrollee’s growth velocity is 2.76 centimeters over a nine month span, which is below the tenth percentile for growth velocity for gender, age and pubertal status. Insulin-like growth factor (IGF-1) level is greater than -2 standard deviation scores (SDS) from the mean for age and pubertal status, which is low. He has a current height on the tenth percentile, while his midparental height (MPH) is 6’2” or 97th percentile. He has a final height prediction of 68.5 inches, which is greater than 2 SDS below his MPH.

The enrollee’s parent is requesting authorization and coverage for the medication Nutropin AQ Nuspin. The enrollee has a diagnosis of growth hormone (GH) deficiency. He has a history of poor linear growth velocity. His GH stimulation test with clonidine and L-dopa peaked at 2.8 and 1.4; respectively. His bone age was 11 years, six months when his chronological age was 14 years, three months. A progress note reported a height of 5 feet 2.8 inches and a weight of 124 pounds, 14.4 ounces. The pediatric endocrinologist notes consensus guidelines recommend growth hormone therapy for a child diagnosed with growth hormone deficiency. The enrollee is at Tanner Stage I. His mid-parental target height is 72.6 inches. In order for the enrollee to meet his mid-parental height (MPH) target, he would need to follow the growth curve at the 75th percentile.

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 Nutropin Aq Nuspin, then check the rights and deadlines that apply to your plan.