Doctor outraged after Medicaid provider denies children medication coverage

Travis Perry
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Posted: Jan 10, 2014 12:09 PM
Doctor outraged after Medicaid provider denies children medication coverage

DENIED: James Casey, a pediatric endocrinologist in Topeka, charges KanCare provider Sunflower State Health with denying children coverage for necessary medication.

By Travis Perry │ Kansas Watchdog

OSAWATOMIE, Kan. — A Topeka doctor is up in arms after a decision by KanCare provider Sunflower State Health resulted in children being denied medication coverage.

James Casey, a pediatric endocrinologist at Cotton-O’Neil Clinic, charges the Medicaid managed care organization with making a blanket decision that has revoked growth hormone therapy coverage for numerous people who seek treatment at the clinic.

Casey told Kansas Watchdog that Sunflower requested his patient’s medical charts in November and said he was greeted with the denial notices after returning from Christmas break.

“The denials just started coming this week,” Casey said Tuesday. “This week we’ve gotten 10.”

But officials with Sunflower State Health say the decisions were made in accordance with Medicaid guidelines set forth by the Kansas Drug Utilization Review program in 2007.

At issue is the use of growth hormone therapy to treat youths whose bodies are either not growing at the expected rate with no obvious cause – referred to as Idiopathic Short Stature – or who have been diagnosed with a pituitary disorder preventing them from naturally producing the hormone. While state Medicaid DUR guidelines permit the use of growth hormone therapy to treat pituitary disorders, it does not cover treatment for an idiopathic diagnosis.

The problem, Casey said, is that no matter the diagnosis, both conditions would result in a child’s medical chart describing them as having “short stature” because of their physical size. In turn, he said, Sunflower has made overly broad decisions in denying what he considers necessary medical treatment. Clinic RN Chris Hammer said of the 10 denial notices the clinic has received, only one patient was given an idiopathic diagnosis, while the rest had a documented growth hormone deficiency.

“This is what I do, as a pediatric endocrinologist,” Casey said. “There aren’t very many of us, and those of us in Kansas have a real vested interest in these kids, and we don’t want anything bad to happen because somebody in KanCare or Sunflower doesn’t understand enough about the diagnosis to know we wouldn’t give anybody growth hormone without having a reason for it. I haven’t done anything like that in my entire life.”

Katherine Friedebach, medical director for Sunflower State Health, told Kansas Watchdog the MCO in no way intends to prevent patients from receiving medically necessary care, but she said Sunflower plans to adhere to state guidelines.

Dr. James Casey

“If a member has just strictly short stature without a growth hormone deficiency, we won’t continue to approve that medication,” Friedebach said. “If there is evidence of a growth hormone deficiency, then we will be sure those members get the treatment that they need.”

Friedebach was unable to specify how many denials had been appealed but said all were upheld by the state. She said Sunflower plans to take a closer look at the patients in question to ensure no mistakes were made.

“I think there could be a miscommunication in what he (Casey) is seeing and what we have received,” Friedebach said. “I’m anxious to look at the charts”

According to figures provided by Casey, the cost for growth hormone therapy ranges between $1,500 and $12,750 per month, meaning, without coverage, individuals who qualify for Medicaid would probably be unable to afford the cost.

“Yes, it’s very expensive, but it’s lifesaving,” Casey said.

“They’re doing our patients a disservice,” he added.

Todd Lupz, director of managed care for Stormont Vail Healthcare, which oversees the Cotton-O’neil Clinic, said Friday that initial media inquiries by Kansas Watchdog had already spurred Sunflower to take action on Casey’s concerns. Lupz said Stormont Vail is taking internal steps to make sure that children don’t miss a medication dose because of bureaucratic red tape.

“I think just by (Casey) maybe mentioning that to you, it certainly got their attention,” Lupz told Kansas Watchdog.

Contact Travis Perry at travis@kansaswatchdog.org, or follow him on Twitter at @muckraker62. Like Watchdog.org? Click HERE to get breaking news alerts in YOUR state!

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