Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth hormone deficiency
Treatment: Nutropin
The health plan denied Nutropin.
The determination is overturned.


The patient is diagnosed with growth hormone deficiency (GHD). This request is for Nutropin. As reported; she started growth hormone (GH) therapy and is on 1.4 milligrams (mg) daily. Her growth hormone (GH) stimulation test with arginine and glucagon peaked at 8.7 and 8.9 respectively. Her pretreatment height velocity is reported to be 3.3 centimeters per year (cm/yr). Her height velocity on therapy is 2.2 cm/yr. Her magnetic resonance imaging (MRI) was normal. She had the onset of menarche (spotting). She gets her menses every 2-3 months. Her  breasts and pubic hair were at Tanner 4. Her Insulin-like Growth Factor 1 (IGF1) was 144 and 190 (range 97-332 mean 194 ); Insulin-like growth factor binding protein 3 (IGFBP3) was 3.96 (2.36-6.06 ). Her weight was 45.20 kilograms (kg).
Her pretreatment height was 129 cm (-1.05 standard deviation score (SDS)) and 137.6 cm (-1.22 SDS) with height velocity of 4.5 cm/yr. Her mother's height is 154.94 cm and father's height is 172.72 cm and mid parental height is 157.33 cm (-0.93 SDS).
At issue is the medical necessity of Nutropin.

The Nutropin is medically necessary. 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 deviations (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 (yr) more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 yr in children over 2 yr of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 yr or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10 nanograms/milliliter (ng/ml).
The denial was based on the patient's bone age and the patient having achieved midparental target height. The standard of care regarding discontinuation of growth hormone is to discontinue growth hormone once growth plates fuse or once the height velocity slows to less than 2 cm/year. The patient has open growth plates based on a bone age of 14 and the height velocity continues to be more than 2 cm/year. Continuation of growth hormone is consistent with generally accepted standards of medical practice and is therefore medically necessary.