Appeal type: Medical Necessity
Decision: Upheld

 The enrollees parent is requesting authorization and coverage for the medication Nutropin AQ Nuspin. The enrollee has a diagnosis of growth hormone (GH) deficiency. He has a history of poor linear growth velocity. His GH stimulation test with clonidine and L-dopa peaked at 2.8 and 1.4; respectively.  His bone age was 11 years, six months when his chronological age was 14 years, three months. A progress note reported a height of 5 feet 2.8 inches and a weight of 124 pounds, 14.4 ounces. The pediatric endocrinologist notes consensus guidelines recommend growth hormone therapy for a child diagnosed with growth hormone deficiency. The enrollee is at Tanner Stage I.  His mid-parental target height is 72.6 inches. In order for the enrollee to meet his mid-parental height (MPH) target, he would need to follow the growth curve at the 75th percentile. However, he is currently tracking at the 15.8 percentile, with a projected adult height of less than 67 inches. The enrollee is currently more than three standard deviations (SDS) below his mid-parental targeted height. His provider asserts growth hormone therapy is crucial for the enrollees development. Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by professional societies. The diagnosis of GH deficiency 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  severe short stature; defined as a height more than three SDS below the mean; a height more than 1.5 SDS below the mid-parental height; a height more than two SDS below the mean and a height velocity over one year of more than one 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; and, in the absence of short stature, a height velocity more than two 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 of less than 10ng/ml. GH stimulation testing for this enrollee peaked at less than 10ng/ml.  The enrollee had a normal IGF1. The enrollee did not meet auxological criteria as pretreatment height and height velocity are normal. Although the enrollees height is significantly below midparental height, his bone age is severely delayed and his height prediction is normal. The physician reviewer found that  pediatric endocrine society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Approval for this indication is for non-growth hormone-deficient short stature. This is defined by a height SDS of 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 persons 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 pretreatment height less than or equal to -2.25 SD