Short Stature denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested growth hormone therapy, Genotropin (somatropin) injection, for treatment of the enrollee’s short stature. Findings: The physician reviewer found that review of the submitted documentation reveals the patient has extreme short stature with normal weight for height ratio, poor growth velocity, low IGF-1 level, and a delayed bone age. Although her peak GH response on provocative GH testing was normal, she meets standard criteria, as established by the Pediatric Endocrinology Society for treatment with GH. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested the Growth Hormone (GH) therapy medication Humatrope 12 mg cartridge for treatment of the enrollee’s short stature. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication. This patient has extreme short stature and normal weight for height ratio, with an adult predicted height that is three standard deviations (SD) below the mean for adult standards in the United States. Although he has had normal growth factors, and GH stimulation testing has not been performed, this patient meets the Pediatric Endocrinology Society (PES) guidelines (Gharib, et al; Wilson, et al).

Where the denial was 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 patient’s brain was noted to be normal. The provider noted that the patient’s 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.

Nature of Statutory Criteria/Case Summary: The patient is a 14-year-old male who has been diagnosed with short stature. On 7/14/17, his height was 136.4 cm, which was -1.7 cm standard deviations below the mean, as extrapolated by the expert reviewer using standard pediatric growth charts, placing him in the fourth percentile. On 11/20/17, the patient’s height was noted to be in the third percentile. A growth chart was not provided with the heights of the patient prior to initiation of growth hormone (GH). Treatment with somatropin was initiated sometime between July 2017 and November 2017. On 9/12/18, the patient’s height had increased from the third percentile to the tenth percentile, with a height of 149 cm. On 3/15/19, the patient’s height was 153.9 cm. His bone age was reported to be 13 years and six months at the chronological age of 13 years and seven months.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving short stature, then check the rights and deadlines that apply to your plan.