Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low insulin-like growth factor 1 (IGF-I) and Panhypopituitarism.
Treatment: Norditropin FlexPro 5MG/1.5ML SC SOPN. 

The insurer denied coverage for Norditropin FlexPro 5MG/1.5ML SC SOPN. The denial is overturned. 

This patient is a female child diagnosed with craniopharyngioma. This request is for Norditropin. She is status post-surgical resection for the treatment of craniopharyngioma. She presented with a history of unexplained weight loss, lethargy, loss of appetite and deteriorating vision. Abnormal eye exam prompted the performance of a Computed Tomography (CT) of the head which showed a large, calcified lesion in the sellar area with profound hydrocephalus. Left endoscopic cyst fenestration with Endoscopic third ventriculostomy (ETV) placement was performed. The Trans-sphenoidal approach radical resection was performed and pathology returned as craniopharyngioma, adamantinomatous, World Health Organization (WHO) Grade 1. The patient's vision returned to normal after surgery. She is on desmopressin for diabetes insipidus, Synthroid for thyroid stimulating hormone (TSH) deficiency and hydrocortisone for Adrenocorticotropic hormone (ACTH) deficiency.

The patient initially did not have a thirst mechanism but does now have a thirst mechanism. She did have complaints of headaches, with an admission for evaluation, and repeat magnetic resonance imaging (MRI) was normal. The headaches are suspected to be possibly due to sinusitis, and she was started on antibiotics. Her MRI of the brain showed status post gross total resection of the previously noted suprasellar hypothalamic craniopharyngioma midline nasal transsphenoidal approach without findings to suggest residual or recurrent tumor and no MRI findings suggestive of intracranial hypotension. Her follow-up MRI of the brain showed status post gross total resection of the previously noted suprasellar hypothalamic craniopharyngioma midline nasal transsphenoidal approach without findings to suggest residual or recurrent tumor. 

The health plan did not act in the best interest of the patient, as the request is medically necessary as described below.

The accepted criteria for the diagnosis of growth hormone (GH) deficiency are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [3]. Patients with panhypopituitarism due to pituitary surgery that damages the pituitary are treated with growth hormone based on the findings of other pituitary hormone deficiencies and biochemical evidence of growth hormone deficiency such as a low insulin-like growth factor 1 (IGF-I) or growth hormone stimulation testing. The patient has a low IGF-I in the setting of having had a craniopharyngioma surgery that destroyed the pituitary and has panhypopituitarism. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The insurer's denial of coverage for Norditropin FlexPro 5MG/1.5ML SC SOPN is overturned. Medical Necessity is substantiated.