Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: This patient has been diagnosed with short stature. The patient was growing along the 25th percentile at the age of 10 years old, based on the growth chart provided, then his height began to decelerate. The provider noted the patient was briefly treated with growth hormone prior to being diagnosed with autoimmune hepatitis. The patient continued to be treated with prednisone 10 mg daily, azathioprine, and Lexapro. The patient was noted to have failed growth hormone stimulation testing with peaks of 6.3 and 7.2 ng/ml. Magnetic resonance imaging (MRI) of the patients brain was noted to be normal. The provider noted that the patients last bone age obtained in February 2019 was 12.5 years old. The provider noted the diagnosis of autoimmune hepatitis likely explains the progressive height deceleration observed in the patient. The patients parent has requested authorization and coverage for Nutropin AQ Nuspin 20 mg. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Nutropin AQ Nuspin 20 mg is medically necessary for the treatment of the patients medical condition. Researchers reported In 2003, the U.S. Food and Drug Administration (FDA) expanded growth hormone (GH) use to the treatment of idiopathic short stature (ISS), also called non-GH-deficient short stature, defined by height standard deviation score (SDS) less than or equal to  2.25 (less than or equal to the  1.2nd percentile) and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients for whom diagnostic evaluation excludes other causes of short stature that should be observed or treated by other means. In this case, the patient is not below -2.25 standard deviations for his age and gender and does not meet the criteria for GH based on the diagnosis of idiopathic short stature. The provider noted the patients bone age in February 2019 was 12.5 years of age, and the estimated predicted height of the patient was 66.5 inches, which is within accepted range for his genetic potential and within an accepted range for an adult male. Researchers reported, Glucocorticoids modulate the secretion of growth hormone (GH) by various and competing effects on the hypothalamus and pituitary gland. The authors also noted, Chronically raised levels of glucocorticoids suppress the secretion of GH. In this case, the patients poor growth velocity is likely explained by the diagnosis of autoimmune hepatitis and high-dose glucocorticoids. The medical evidence does not support the requested medication in this clinical setting. Therefore, Nutropin AQ Nuspin 20 mg is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in 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 a similar medical condition.