Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 14-year-old male who has been diagnosed with neurosecretory defect or functional growth hormone deficiency. He has continued to drop percentages over several years from the 25th percentile to the 10th percentile with his growth velocity below the 3rd percentile for his age and gender. His parents report that based on observations over a 15-month period in addition to a low IGF-1 level and IGFBP3 level, his physician indicates the patients height percentiles will continue to drop. Therefore, growth hormone therapy has been recommended. The Health Plan has determined growth hormone therapy is not medically necessary for treatment of the patients medical condition.This patient was seen for short stature by a pediatric endocrinologist in December 2003. His height then was 152cm and weight was 84 pounds, which were respectively between the 10th and 25th percentiles and between the 5th and 10th percentiles. Historically, prior measurements showed height progressing between the 25th percentile and 50th percentile from age 8 to 12 years with weight along the 25th percentile. Growth velocity throughout this time interval was 6cm per year, above the 25th percentile for chronological age, projecting a final height of around 58 and, as such well within the mid-parental height determined target height of 57-511 (+/- 1 standard deviation). The patients height and weight fell off between the 12th and 13th birthday to between the 10th and 25th percentile in height and to the 10th percentile in weight. His height velocity for this year interval was 3cm per year and thus below the 3rd percentile for either chronological or bone age. History and examination were negative for any signs or symptoms to support a pathologic diagnosis. Thorough endocrine evaluation was undertaken in December 2003 after a referral to a specialist. The evaluation confirmed the absence of any specific pathologic condition to explain the decreased growth and weight gain the preceding year. The only potentially abnormal findings were that of a consistently low IGF-1 level of 92ng/ml in Sept. 2003, and a borderline low IGFBP-3 of 2.1, on one occasion in October 2003. Of note however, the patients height increase between his 13th birthday and the date of his pediatric endocrinology consultation was 5cm in 9 months. Follow-up visit confirmed this re-establishment of an age appropriate growth velocity with a confirmed additional height increase of 1.7cm over 3 months. These findings continued to a height velocity of 6.7 cm/year between the patients 13th and 14th birthday. This occurred before any growth hormone therapy was initiated. Agreeably, the start of growth hormone therapy was associated with a measurable increase in both IGF-1 levels and growth velocity. However, these improvements were associated with a described progression in the patients pubertal development, a process that in itself can cause a distinct growth spurt and an increase in IGF-1 levels. In fact, an IGF-1 level obtained on 2/26/04 (before starting growth hormone therapy) was recorded at 176ng/ml, which although still below the expected range for the patients age, was nonetheless substantially improved. This finding suggests an alternative etiology for the initially decreased levels other than growth hormone deficiency or inactivity.Given the above analysis of the available information, it appears the patients decreased growth velocity and poor weight gain between his 12th and 13th birthday were the result of a physiologic growth deceleration before pubertal onset, a variant of hormonal growth and development not infrequently described yet poorly explained. The documentation of an acceptable growth velocity and an increasing IGF-1 level prior to initiation of growth hormone therapy lends support to a benign, transient delay in physical and maturational development as the most likely diagnosis. Under this interpretation, growth hormone therapy is not medically necessary for this patient.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.