Diagnosis: Growth hormone deficiency

Treatment: Norditropin

The insurer denied coverage for Norditropin

The denial is overturned.

This is a female child diagnosed with growth hormone (GH) deficiency. This request is for Norditropin. Her GH stimulation test with clonidine and arginine peaked at 3.39. Her MRI ruled out a pituitary issue. Her bone age was 7 years 10 months at chronological age (CA) of 7 years 4 months, then was 8 years 9 months at CA of 8 years 6 months, and was 10 years at CA of 9 years 8 months. Her IGF1 was 224 and her IGFBP3 was 5.8. She is at Tanner stage 1.

Her mother's height is 149.86 cm and father's height is 160.02 cm and mid parental height is 148.44 cm, which is a -2.29 standard deviation score (SDS).

Her height at 8.491 years old was 122cm (-1.39 SDS) and at 10 years old was 127.508 cm (-1.64 SDS) with height velocity over 1 year 6 months of 3.7 cm/yr, which is -2.5 standard deviations.

Classic GH 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 SD below the mean; 2) height more than 1.5 standard deviations (SD) below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. The patient met height criterion 4 as height velocity over 1.5 years was more than 2 SD below the mean. The patient met both height and height velocity and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient is the request is medically necessary as described below.

Based on the above, the medical necessity for Norditropin is substantiated. The insurer's denial is overturned.