Diagnosis: Idiopathic Short Stature.
Treatment: Humatrope.

The insurer denied the Humatrope.
The determination is upheld.

The patient is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS). His past medical history is significant for developmental delay, coronal hypospadias, obsessive compulsive disorder and the diagnosis of Tourette syndrome. His reported mid parental height is 170.3 centimeters (cm) (67 inches). His growth chart shows that his height was around the 10 percentile (%tile). His weight was around the 50 %tile, dropped to around 25 %tile, and 10 %tile. His evaluation showed an unremarkable comprehensive metabolic panel (CMP), thyroid function test (TFTs), celiac screen, pubertal follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone. Insulin-like growth factor (IGF) -1 and insulin-like growth factor binding protein-3 (IGFBP-3) were normal.
He was evaluated in the pediatric endocrinology clinic. At that time, his height was 143 cm (6.71 %tile:-1.5 standard deviations (SD)) while his weight was 37.4 kilograms (kg) (17 %tile -1.0 SD). The clinical impression was familial short stature. His growth was followed and on the follow up visit, his height was 149.9 cm (5.65 %tile:-1.58 SD) while his weight was 36.4 kg (3%tile:-1.95 SD). The clinical impression was familial short stature.
He underwent GH stimulation testing and his peak growth hormone (GH) response was 18.3 nanograms/milliliter (ng/ml). Treatment with GH was recommended under the indication of idiopathic short stature, At this most recent follow up visit, his height was 153.4 cm (2.77 %tile:-1.92 SD). He was Tanner stage V for pubertal development.
At issue is the medical necessity of Humatrope.

The requested service is not medically necessary for this patient.

Although this patient's growth slowed down and he dropped height percentiles, it was associated with a significant drop in weight percentile suggesting nutritional growth retardation (NGR) rather than idiopathic short stature. NGR patients may cease to gain appropriate weight and fail to grow in height even without exhibiting body weight deficits for height. His slow growth cannot be considered idiopathic.
Although overall this patient has grown at a rate of 5.1 cm per year in 2 years which is less than expected, considering the fact that he was in puberty; however, his slow growth was associated with poor weight gain suggesting familial short stature complicated by nutritional growth failure. Besides that, at his most recent follow up visit, he was Tanner stage V for pubertal development suggesting that he has almost finished his growth and any intervention at this point is unlikely to improve his adult height.