Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short Stature
Treatment: Genotropin
The insurer denied the Genotropin
The denial is overturned

The patient is a male under review for idiopathic short stature. The patient's birth weight was approximately seven pounds three ounces but no length was given. An overview of the growth chart reveals that the patient grew about ten percent until a few years ago, then fell to seven to eight percent until approximately a year ago, then below five percent to current age, when he fell less than three percent. Growth hormone (GH) therapy has pulled this up to four to five percent. 

Labs from approximately three years prior showed insulin-like growth factor one (IGF-1) of 325 (87-519), and insulin like growth factor binding protein three (IGFBP3) of 4157 (2463-6093). Free thyroxine (FT4), thyroid stimulating hormone (TSH), and thyroid peroxidase (TPO) were normal but anti-thyroglobulin was 3.7 (less than 0.9), suggestive of Hashimoto's thyroiditis. Other conditions included coronal hypospadias corrections, developmental delay, obsessive compulsive disorder (OCD), and Tourette's tics. Other lab included normal comprehensive metabolic panel (CMP), urine analysis (U/A), celiac, luteinizing hormone (LH)/follicular stimulating hormone (FSH), testosterone, estrone, estradiol, inhibin B, dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone (17-OHP), and aldosterone. The patient's lipids were 229/93/55/155. 

At visit approximately three years prior, the patient's height was 143 centimeters (cm) with right testis ten cubic centimeters (cc) and left 5.5 cc, called premature adrenarche. On visit approximately two years ago, the patient's height was 147.3 centimeters without pubertal exam. On visit approximately three months later, the patient's height was 150 centimeters (five percent) with right breast Tanner-stage II (TS2), right testis 11 cubic centimeters, and left eight cubic centimeters with Tanner-stage III (TS3) pubic hair. His predicted height of five feet three inches. The patient's mid-parental height (MPH) was 66.5 inches, about the height of the father. On visit approximately one year ago and then approximately four months later, the patient's height 152.3 centimeters (four percent) with breasts at Tanner-stage II, right testis 18 cubic centimeters (cc) and left 20 cubic centimeters with Tanner-stage IV pubic hair. 

The patient underwent growth hormone stimulation testing with a fasting growth hormone of 9.38 and a three-hour level of 18.30 (greater than ten). Now on growth hormone, the patient's predicted height was 61.5 inches. Growth velocity (GV) over approximately six months was calculated as 3.81 centimeters per year. Insulin-like growth factor one (IGF-1) was 457 (123-701).  On visit approximately six months ago, he showed height of 154.5 centimeters (three percent). He was now on anastrozole to slow down pubertal advancement of his bone age. Breasts were Tanner-stage one, right testis 20 cubic centimeters and left 15 cubic centimeters with Tanner-stage IV (four) pubic hair. On the last visit approximately three months ago, the patient's height was 62 inches (four percent), exceeding the last predicted height. There was no computed tomography/magnetic resonance image of the pituitary documented.

Yes, the proposed treatment with Genotropin is medically necessary.
The patient's statural growth has gradually fallen to less than three percent, as his bone age remains advanced yielding a predicted height up to five inches below the mid-parental height. Although the patient never fell below - (minus) 2.25 standard deviations scores (SDS), he should be assessed according to his genetic potential. Even with continued growth hormone and anastrozole therapy, the patient will not catch up more than one to two inches, and if he were not treated, he would likely have continued to fall behind enough to meet the usual statistical standard, albeit too late to intervene on his behalf.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
A patient needs to be evaluated based on their performance against their genetic potential. This patient clearly was not meeting mid-parental height expectations. The recommended length of approval is for six months with another height measurement and bone age so that a predicted height may be calculated to ascertain further growth potential, if any.