Evaluation of Coverage of Growth Hormone
At first look, the handbook is a daunting document; but, it’s not so difficult when it is broken down to its parts. It becomes more clear when, in each part, one looks for information relevant to disorders of growth and growth hormone. Below are the parts and provisions that relate to, or may relate to, disorders of growth and growth hormone:
COVERAGE AND MEDICAL NECESSITY
“Coverage” concerns the diseases, disorders, conditions, or illnesses; and, the drugs, product, or services for which the insurance company will provide benefits.
“Medical Necessity” concerns the need for inpatient and outpatient drugs, products, or services in the diagnosis, treatment, and management for a disease, disorder, condition, or illness, for which there is “coverage” under the insurance policy.
A disease, disorder, condition, or illness of the beneficiary may meet the criteria for “medical necessity;” but, may be expressly excluded from “coverage;” or, the drug, product, or service (including diagnostic procedure) may be excluded specifically or because it is considered experimental or investigational. In that instance a claim or appeal may not be sustainable. Likewise, the beneficiary may meet the criteria for coverage; but, not meet the criteria for “medical necessity.” Denial of “medical necessity” is appealable where an appeal is available.
WHERE TO LOOK FOR COVERAGE AND EXCLUSIONS
The insurance handbook contains the basics of coverage and exclusions for the diagnosis and treatment diseases, disorders, conditions, or illness; and the drugs, products, and services for disorders of growth or growth hormone.
1. Look under parts of the handbook with titles that concern coverage or exclusion of coverage for drugs, products or services, and provisions that contain any of the following words:
a. growth hormone, growth hormone deficiency, partial growth hormone deficiency, growth hormone insufficiency, or growth hormone insensitivity syndrome, or IGF Deficiency syndrome; or bioinactive growth hormone;
b. Intrauterine growth retardation (IUGR), small-for-gestational age (SGA), Prader-Willi syndrome, Turner syndrome, Down syndrome, Noonan syndrome, chronic renal failure, Idipathic Short Stature (ISS), growth hormone neuroscretory dysfunction; or,
c. constitutional delay of growth and maturation (CDGM), familial short stature.
2. Look under parts of the handbook that concern coverage or exclusion of coverage for drugs, products or services, and provisions that contains the words in connection with a condition involving growth hormone, or growth hormone deficiency or short stature:
a. tumor, lesion, or cancer, pitutitary, hypopituitarism, panhypopituitarism; multiple hormone deficiency, metabolic diseases or disorders;
b. malabsorption and gastrointestinal diseases, such as celiac disesae and Crohn disease, including G (IgG) and IgA antigliadin and IgA antiendomysial antibodies ;
c. chronic liver disease, cardiovascular disease, renal disease, hematologic disorders, including chronic anemias (e.g., sickle cell disease), thalassemia;
d. hypothyroidism, gonadal failure, hypogonadatropic hypogonadism, Cushing syndrome (glucocortcoid excess), pseudohypoparathyroidism, rickets (hypovitaminoisis D or vitamin D resistant), diabetes (e.g., Mauriac syndrome), errors of inborn metabolism, including glycogen storage disease, chronic inflammation and infection (e.g., Crohn disease, cystic fibrosis (CF), juvenile rheumatoid arthritis, human immunodeficency deficiency virus (HIV);
3. Look under the parts of the handbook that concern definitions of
“coverage,” “medical necessity,” exclusions,” “exceptions,” “exceptions,” “investigational,” “experimental,” and, any provision that, in substance, expressly states that the insurance company may exercise its discretion to consider individivual circumstances in approving coverage.
4. Look under the parts of the handbook that concern claims and appeals. Check to see the following:
a. whether the provisions provide for an appeal, whether there is one or two levels of internal appeals, and whether there is independent review at the State level after or before the internal appeals have been exhausted;
b. what kind of administrative process the insurance companies provides: whether there is a right to a hearing, how the hearing is conducted, and who are the persons (title and position) of the persons who decide the appeals; and
c. what are the time periods for filing each level of appeal, with which you must comply.