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

The case involves a 12-year old male who has been diagnosed with idiopathic short stature and for whom growth hormone (GH) therapy had been prescribed over the previous year with an excellent growth response. A two-point growth chart indicated that the patients height was -2.25 standard deviations (SD) below the mean and in the 3rd percentile at age 11. A physicians note indicated a height response of 3.25 in 11 months of GH therapy through April 2005. The notes were largely handwritten with limited detailed information. Nevertheless, the parents were 6 and 56 tall giving a mid-parental height potential or target height of 71.  A predicted final adult height based upon data from 9/01 was given as 53. 6. Other lab data indicated a low IGF-1 level (the stage of development to judge this against was not provided but it is low even if the patient was pre-pubertal at the time) but the IGFBP-3 level was normal. GH provocative testing showed a peak GH level of 18 ng/ml, which would rule out GH deficiency. Additional physician notes suggest there was an elevated sedimentation rate (value not given) and other serology raising a suspicion of celiac disease. IgA transglutaminase antibodies and jejunal biopsy were apparently done with negative results and ruled out a diagnosis of celiac disease. Inflammatory bowel disease was also contemplated but no follow-up sedimentation rates were cited.  A list of medications indicated that Zoloft had been prescribed. At issue is whether growth hormone therapy is medically necessary for treatment of the patients condition. Given the lack of evidence of a GH deficiency and the delay of three years in bone age, the likely diagnosis in this case would seem to be constitutionally delayed adolescence. Additionally, the bone age readings appeared inconsistent, making it difficult to adequately judge the patients adult height and the possibility of inflammatory bowel disease had not been fully ruled out based on the records provided.  However, there are sufficient indications for GH therapy which include a height greater than -2.25 SD below the mean (prior to GH therapy), an adult predicted height in the short adult range despite relatively tall parents, a low IGF-1 level, and an excellent response to GH (Humatrope).  It appears this patients growth failure would meet the FDA guidelines of July 2003 for continued GH therapy; however, there is no evidence the patient has been evaluated and followed by a pediatric endocrinologist. As such, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should be evaluated by a pediatric endocrinologist who should verify the bone age readings and adult height prediction, confirm that the patients gratifying growth response was not due to advancing adolescence, and rule out other causes of growth arrest. If based upon these findings the pediatric endocrinologist recommends continued treatment with growth hormone therapy, the requested therapy should be authorized. Therefore, I have determined the requested growth hormone therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld pending an appropriate response the issues cited previously.