Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature (ISS)

Treatment: Nutropin AQ (somatropin)

The insurer denied coverage for Nutropin AQ.

The denial is upheld.

This is a patient diagnosed with idiopathic short stature (ISS). This request is for Nutropin. His growth hormone (GH) stimulation test peaked at 12.29. His genital development and pubic hair were at tanner 1. His bone age was 9 years at chronological age (CA) 9 years 6 months. His Insulin-like growth factor 1 (IGF1) was 61; Insulin Like Growth Factor Binding Protein 3 (IGFBP3) was 2409 (normal). 

His height at 9.5 years old was 124.7 cm (centimeters) [-1.86 standard deviations score (SDS)] and at 10.08 years old was 127 cm (-1.83 SDS) with height velocity over 0.58 years of 4 centimeters/year (cm/yr). His mother's height is 157.48 cm, his father's height is 165.1 cm, and mid-parental height is 167.79 cm (-1.69 SDS). 

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

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, 3], and the medical guidelines for GH 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 height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD (standard deviations) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml (nanogram per milliliter).
		
The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. FDA (Food and Drug Administration) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS < (less than) -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. 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. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for Nutropin AQ is upheld. Medical necessity is not substantiated.