Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypothyroidism

Treatment: Nature-Throid tablets

The insurer denied coverage for Nature-Throid tablets. The denial was reversed.

This patient is a female diagnosed with hypothyroidism.  The clinical note indicated that the patient was seen for a follow-up.  The patient was diagnosed many years ago and had been stable on the dose of levothyroxine 88 mcg daily.  The patient stated that previous thyroid testing performed the previous month were normal.  The patient has had 2 thyroid ultrasounds 1 of which was in the last couple years and it was normal.  The patient has tried other formulations of the years including Armour, brand and generic Synthroid and Cytomel but continued with complaints of hypothyroidism with symptoms of fatigue, depression and weight gain.  The patient currently reports fatigue, history depression/anxiety and 20 pound weight gain since originally diagnosed.  The patient's sleep pattern was recently improved with the addition of magnesium.  The patient reports a good diet with occasional indiscretions.  The patient was transitioned to Nature-Throid 65 mg in mid-2019.  Most recent TSH was 1.12, free T4 0.7 and total T3 148.  The patient continued to complain of anxiety, difficulty sleeping, and leg weakness. The patient was to continue at the same dose as not to exacerbate the symptoms any further.

The medical literature notes that hypothyroidism is a permanent condition requiring lifelong treatment. Therapy consists of thyroid hormone replacement unless the hypothyroidism is transient (as after painless thyroiditis or subacute thyroiditis) or reversible (due to a drug that can be discontinued). Nature-Throid is indicated as a replacement of supplemental therapy in patients with hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis.  

The patient stated that she has trialed on work, brand and generic Synthroid and Cytomel but continued to experience symptoms of fatigue, depression and weight gain.  The patient was then switched to Nature-Throid. The patient's thyroid function test continued to be normal prior to switch medication and after the switch in medication.  The most recent office note indicated that the patient continued to have symptoms of hypothyroidism.  Levoxyl, Synthroid and Unithroid all have same chemical formulation. The patient has utilized generic Synthroid, Cytomel and armour thyroid with ongoing symptoms. 

Nature-Throid is gluten free and has T3 plus T4 components which helps with symptomatic hypothyroidism, whereas all the other medicines that she tried before were T4 formulations and only one was (cytomel) T3 but in lower doses than what is present in Nature-Throid.  So, even if thyroid function tests are normal, symptomatic hypothyroid patients benefit from dessicated thyroid medicine given the ratio of T3 and T4 in that formulation. 

Therefore, the requested Nature-Throid tablets would be medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Nature-Throid tablets is substantiated.  The insurer's denial is reverse