Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature
Treatment: Norditropin Flex Pro
The health plan denied the Norditropin Flex Pro.
The health plan's determination is overturned.

This is a male diagnosed with idiopathic short stature (ISS). This request is for Norditropin. As reported, he started growth hormone (GH) therapy with Somatropin.  His height velocity is reported to be improved from 0.5 centimeters/year (cm/yr) to 11.8 cm/yr. His GH stimulation test with Arginine and Glucagon peaked at 13. His bone age was 13 years at chronological age (CA) 14 years; he was 10 years 2 months at CA 10 years 7 months. His Insulin-like growth factor binding protein 3 (IGFBP3) was 5.46 (page106); Insulin-like Growth Factor 1 (IGF1) was 353 (page 108). His weight was 45.3 kilograms (kg).
The patient's pretreatment height at 11.43 years old was 129.7centimeters (cm) (-2.32 standard deviation score (SDS)) and at 12.2 years old was 132.1 cm (-2.52 SDS) with height velocity over 0.77 years of 3.1 cm/yr. His height on therapy at 14.27 years was 150.6 cm (-1.83 SDS). His mid parental height is 169.1 cm (-1.08 SDS).
At issue is the medical necessity for the requested Norditropin Flex Pro.

The health plan's determination of medical necessity is overturned, in whole.

Yes. Norditropin Flex Pro is medically necessary for this patient.
The peer reviewed literature including consensus clinical guidelines, 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 standard deviation (SD) 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 10 nanograms/milliliter (ng/ml).

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9] Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS 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."[10-13]
The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria.
The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.