Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Nutropin AQ Nuspin 10
The insurer denied: Nutropin AQ Nuspin 10
The denial is upheld.

The patient is a school aged female diagnosed with ISS (idiopathic short stature). This request is for Nutropin. The patient's bone age eight months ago was 8 years 10 months. Seven months ago, her breasts and pubic hair were at tanner 1 and her IGF1 (her insulin-like growth factor 1) was 138 (64-259; mean 142); IGFBP3 (insulin-like growth factor binding protein 
3) was 3.29 (2.1-5.6). She had a normal genetic female Karyotype test. Her weight was 97.8 pounds.
The patient's height last year was 115.57 centimeters (-2.2 SDS [standard deviation score],) and seven months ago was 119.7 centimeters (-1.94 SD [standard deviation]) with height velocity over 7 months of 6.7 centimeters/year. The patient's mid-parental height is 160.02 centimeters (-0.51 SDS [standard deviation score]). Her predicted adult height is 145.288 centimeters (-2.77 SDS [standard deviation score]).

The requested Nutropin is not medically necessary.

The peer-reviewed literature, including consensus clinical guidelines and randomized controlled trials, are summarized below:

Classic GH (growth hormone) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH (growth hormone) deficiency published by the GH (growth hormone) research society (1), the Lawson Wilkins Pediatric Endocrinology Society (2, 3), and the medical guidelines for GH (growth hormone) use provided by the American Association of Clinical Endocrinologists (4). The above-referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings.
The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are
1) Severe short stature, defined as a height of more than 3 SD (standard deviation) below the mean;
2) Height of more than 1.5 SD (standard deviation) below the midparental height;
3) Height of more than 2 SD (standard deviation) below the mean, and a height velocity over one year of more than 1 SD (standard deviation) below the mean for chronological age, or a 
decrease in height SD (standard deviation) of more than 0.5 over one year in children over two years of age;
4) In the absence of short stature, a height velocity of more than 2 SD (standard deviation) below the mean over one year, or more than 1.5 SD (standard deviation) sustained over two years.

The biochemical criteria include low IGF1 (insulin-like growth factor 1) or IGFBP3 (insulin-like growth factor binding protein 3) or GH (growth hormone) stimulation testing, with a peak GH (growth hormone) of less than 10 ng/ml (nanograms per milliliter).
The patient did not meet biochemical criteria. Growth hormone stimulation testing is not reported, and growth factors are normal.

Idiopathic Short stature:
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. FDA (United States Food and Drug Administration) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS [standard deviation score] less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."[10-13]
The patient does not have a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient therefore does not meet idiopathic short stature criteria.
The request does not meet any nationally accepted criteria for use of growth hormone. Therefore, the request is not medically necessary.