Diagnosis: Hypogonadism.
Treatment: Chorionic Gonadotropin 10000 units intramuscular (IM) solution reconstituted.

The insurer denied coverage for Chorionic Gonadotropin 10000 units intramuscular (IM) solution reconstituted.

The denial is overturned.

This case involves a young adult under review for coverage of Chorionic Gonadotropin. The laboratory report revealed a low testosterone level of 51. Testing seven weeks later showed a low level of 208. Lab results also showed high Luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels. A clinical note reported the patient had a diagnosis of hypogonadism and Klinefelter syndrome. Current medications included Chorionic Gonadotropin as well as anastrozole. The determination letter reported the requested medication was denied due to a lack of documentation of failure of preferred formulary alternatives to include testosterone cypionate and testosterone enanthate. The letter reported the patient was on Clomid, but testosterone levels were not improving. It was noted that the formulary medication would not be fit for the patient due to a disruption of sperm production. The patient was recommended for Human Chorionic Gonadotropin to help improve testosterone levels.

Chorionic Gonadotropin 10000 units intramuscular (IM) solution reconstituted is considered medically necessary for this patient. In this case, the patient has evidence of low testosterone levels. Given his current age and fertility issues, the formulary alternatives of testosterone cypionate and testosterone enanthate are contraindicated. The use of Human Chorionic Gonadotropin would be supported and medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for Chorionic Gonadotropin 10000 units intramuscular (IM) solution reconstituted is substantiated.