Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for the medication, Nutropin AQ NuSpin 20mg, due to concerns for short stature.  The enrollee has familial short stature, with height deceleration from a prior third percentile to the more recent first percentile. A work-up showed he was not growth hormone (GH) deficient.  At his initial endocrinology visit, his bone age (BA) was two years delayed.  However, by the next year, his BA was only less than or equal to one year delayed.  His final adult height estimates fell from 67 inches to less than or equal to 64 inches, prompting the baseline lab profiling and subsequent GH stimulation testing.  The enrollees height is more than two standard deviations below the mean, less than the third percentile, for age and sex.  His height velocity is less than the tenth percentile of normal for his age and sex; tracked over at least one year.  Epiphyses are open.  His GH stimulation test peaked at 22.  Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency. The diagnosis is based on auxological, biochemical and sometimes radiological findings.  The auxological 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 scores (SDS) below the mean; 2) height more than 1.5 SDS below the midparental height; 3) height more than 2 SDS below the mean and a height velocity over one year more than 1 SDS below the mean for chronological age, or a decrease in height SDS of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2 SDS below the mean over one year or more than 1.5 SDS sustained over two years.  The biochemical criteria include low insulin-like growth factor 1 (IGF1) or insulin-like growth factor binding protein 3 (IGFBP3) or GH stimulation testing with a peak GH less than 10ng/ml. This enrollee 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. Non-growth hormone-deficient short stature is 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. The enrollee does not have a pre-treatment height less than or equal to -2.25 SDS and does not meet idiopathic short stature criteria. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes & metabolism and pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.