Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  GHD (growth hormone deficiency).
Treatment:  Nutropin.

The insurer denied Nutropin.  The denial is upheld.

The patient is a teenage male diagnosed with GHD (growth hormone deficiency). This request is for Nutropin.

The patient's GH (growth hormone) stimulation test from 3 months ago peaked at 6.6 and 3.43 respectively. His bone age from 5 months ago was 13 years at 13 years 3 months. Also noted 3 months ago his testes were 15 cc (cubic centimeters) at left and 20 cc (cubic centimeters) at right. His pubic hair was at tanner 2. Last month his testes were 6 cc (cubic centimeters) bilaterally, and his pubic hair was at tanner 1. Last month his IGF1 (insulin-like growth factor 1) was 223. His MRI (magnetic resonance imaging) was normal. The patient's weight was 40.4 kg (kilograms).

Per the submitted chart, the patient's height 2 years ago was 139.7 cm (centimeters) (-1.45 SDS [standard deviation score]). Three months ago, it was 147.5 cm (centimeters) (-1.44 SDS [standard deviation score]). His height velocity over one year and two months was 6.6 centimeters per year. His predicted adult height is 168.4 cm (centimeters), -1.18 SD (standard deviation). His height velocity for 10 months of last year was 8.16 cm (centimeters) per year, which is improving with onset of puberty. The patient's mid-parental height is 165.3 cm (centimeters) (-1.61 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
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 height and height velocity criteria, as his pretreatment height and height velocity are normal. His GH (growth hormone) stimulation testing peaked at less than 10ng/ml (nanograms per milliliter).

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 (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."

The patient does not have a pretreatment height less than or equal to -2.25 SD (standard deviations). The patient therefore does not meet idiopathic short stature criteria.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.