Issued and entered November 7, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On September 17, 2002, Petitioner XXXXXXXX, on behalf of her XX year-old son XXXXXXXXXXX, filed a request for external review with the Commissioner of the Office Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request on September 24, 2002.

A determination on medical issues was required. The Commissioner assigned the case to Permedion, an independent review organization (IRO). The Commissioner directed the IRO to provide the opinion and recommendation of a medical expert. Petitioner submitted additional information for review on September 30, 2002, and OFIS forwarded the material to the IRO. Care Choices HMO (Care Choices) submitted its response to Petitioner’s claims to the IRO and to OFIS on October 2, 2002. The IRO completed its review on October 8, 2002. A copy of the report is attached.

II
FACTUAL BACKGROUND

Petitioner’s son is a Care Choices member, covered as a dependent under his father’s subscriber contract. Due to Hypopituitarism, his body does not produce enough growth hormone for him to naturally reach his genetically designed height. He has been undergoing growth hormone therapy to treat this condition for approximately 10 years. Petitioner’s son is within his mid-parental height (between his mother’s and father’s heights), and he is near the 80th percentile of height for boys his age.

In July 2002, Care Choices denied Petitioner’s son coverage for a prescription refill for Humatrope, a growth hormone therapy drug. Care Choices told Petitioner that authorization for the prescription refills was being halted pending a bone age study. Bone age studies showed Petitioner’s son had a bone age of 17. It is Care Choices’s policy to cease coverage of growth hormone therapy for male patients after they attain a bone age of 16. In August 2002, Care Choices informed Petitioner it would no longer cover prescription re-fills for Humatrope for her son. Care Choices gave the reason that Petitioner’s son was no longer eligible for coverage, because he was within his mid-parental height and he had a bone age that was consistent with his chronological age. Petitioner initiated the Care Choices internal grievance process, and Care Choices reached a final adverse determination in her son’s case on September 10, 2002. Care Choices ruled that Petitioner’s son does not meet the medical criteria for continued coverage of growth hormone therapy.

III
ISSUE

Whether Care Choices properly denied Petitioner’s son continued coverage for growth hormone therapy for height?

IV
ANALYSIS

Petitioner’s Argument

Petitioner argues her son’s growth hormone therapy should continue until he reaches his genetically designed height. His growth plates have not yet fused, and he will not be able to reach his optimum height without the treatment. Petitioner believes it is unethical and unacceptable for Care Choices to discontinue her son’s coverage for growth hormone therapy prior to the completion of his growth. She states this has caused him much emotional distress, because he knows his body can still grow and won’t without the necessary hormone for which Care Choices has denied coverage. Petitioner believes that Care Choices should approve coverage for the growth hormone therapy drug Humatrope, because it is medically necessary for her son to attain his complete growth potential.

Care Choices HMO Argument

Care Choices’ final adverse determination letter dated September 10, 2002, stated in part:

…the Member Reconsideration Committee upheld the original adverse determination for the following reasons:

• Patient does not meet criteria for continuation for growth hormone therapy.

Therefore, Care Choices HMO will not authorize [any more] medications [for growth hormone therapy], as they are [a] benefit exclusion under the medical plan that your employer group purchased

IRO’s Recommendation

A practicing physician certified by the American Board of Pediatrics reviewed this case. The medical expert has experience and qualifications in the treatment of patients with conditions similar to Petitioner’s son’s. The reviewer recommended that Care Choices’s final adverse determination in this case be upheld. The medical expert’s recommendation was based on the following conclusions:

• Petitioner’s son has likely already attained his optimum height, as evidenced by his slowed height gain and closing growth plates.
• Petitioner’s son would receive little benefit from continued growth hormone therapy for height.
  

Commissioner’s Review

The Commissioner reviewed all of the documents and argument presented by both parties. The focus of this analysis is whether continued growth hormone therapy for height is medically necessary for Petitioner’s son. The Commissioner concurs with the conclusion and recommendation of the IRO that Petitioner’s son has likely already attained his optimum height, so continued growth hormone therapy for height cannot be medically necessary. Therefore, Care Choices’s final adverse determination in this case is valid.

V
ORDER

It is ORDERED that Care Choices’s September 10, 2002, final adverse determination in Petitioner’s case is upheld. Care Choices is not required to provide Petitioner’s son with any further coverage for growth hormone therapy for height. Care Choice is specifically not required to cover the growth hormone therapy drug Humatrope for Petitioner’s son.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.