Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic Short Stature
Treatment: Nutropin Aq (somatropin) Inj (injection) 10 mg (milligrams) /2 ml (milliliters)
The insurer denied coverage for Nutropin Aq Inj 10 mg/2 ml
The denial is upheld 

This is a young teenager diagnosed with idiopathic short stature (ISS). This request is for Nutropin. His growth hormone (GH) stimulation test with arginine and glucagon peaked at 11. The Insulin Like Growth Factor 1 (IGF1) was 216; the Insulin-like growth factor-binding protein 3 (IGFBP3) was 4.19. His height velocity is reported to be 6.9 centimeters per year (cm/yr). His testes and pubic hair were at tanner 3. His weight was 33.7 kilograms (kg). There was a normal height velocity. His height was 144.8 cm (-2.06 SD) (Standard Deviations). His mid parental height was 171.6 cm (-0.73 SD).

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

Classic GH (growth hormone) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society, the Lawson Wilkins Pediatric Endocrinology Society, and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. 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 yr (year) 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 (Insulin Like Growth Factor 1), IGFBP3 ( Insulin-like growth factor-binding protein 3), or GH (growth hormone) stimulation testing with a peak GH less than 10 nanograms per milliliter (ng/ml).
		
The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Idiopathic Short stature 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviations (SD) 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." 

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. There are no studies showing safety or efficacy of growth hormone in patients such as this patient who has a height taller than -2.25 SD (standard deviation) and has a poor height prediction.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Nutropin Aq Inj 10 mg/2 ml is not substantiated.