HGH, or human growth hormone, is a drug that typically is not covered by most health insurance policies. However, the coverages section of a health insurance policy needs to be reviewed to see if there are any special provisions that apply to HGH. Health insurance policies may contain a provision for drugs and products that are a "medical necessity" for a patient's care. But they may also have a section that lists specific conditions and illnesses that are excluded from coverage.
Medical Necessity
People who have a medical necessity typically require inpatient or outpatient drugs or services regarding a diagnosis of a medical condition, disease or disorder. Coverage for a medical necessity usually includes any treatment and management that is necessary under the health insurance policy. However, even if you have a condition that meets the requirements for a medical necessity, you may find that it is specifically excluded from coverage on the policy. Depending on the type of illness or condition, you can usually make an appeal with the insurance company.
Exclusion Provisions
Most health insurance policies contain a section for certain drugs, products, services and conditions that have been specifically excluded from coverage. In the case of HGH, a policy may contain exclusions for a growth hormone, a growth hormone deficiency, and syndromes such as hormone insensitivity and insulin growth factor (IGF) deficiency. Policy exclusions may also apply if an individual has a delay in growth and maturation or suffers from a condition known as short stature.
Connection with Other Conditions
Within the exclusion section of a health insurance policy, provisions may exist that exclude certain types of drugs, products and services when a condition is in connection with HGH. Such conditions can include suffering from a tumor, cancer, a multiple hormone disorder and a metabolic disease. Other types of conditions include liver disease, renal disease, chronic anemia, and conditions that can cause chronic inflammation and infection.
Individual Consideration
Health insurance policies may contain a provision that gives the insurer the option to provide coverage on a case-by-case basis. This means that an insurance company may use its own discretion concerning individual circumstances when deciding whether to approve coverage for HGH. This provision may be found within the coverage, exclusions, medical necessity and experimental sections of your health insurance policy.
Claims and Appeals
All health insurance policies contain a provision about appealing a denial of a claim. Many appeals need to be made to the insurance company first and may have one or two levels. Appeals can then proceed to an independent review by the state once all appeals to the insurance company have been exhausted. Provisions in a health insurance policy may also indicate a time period during which an appeal can be made.
