Growth Hormone denials in California external review

What the reviewers wrote

Where the denial was overturned

This case concerns a seven-year-old female who was denied coverage for growth hormone (GH) therapy for short stature. The patient had severe intra-uterine growth retardation (IUGR), weighing only three pounds eleven ounces at full term. She failed to undergo catch-up growth by two years of age and demonstrated poor muscle tone with weakness and hypotonia. The patient had hip dysplasia and treatment for clubfeet. She was also treated for wheezy bronchitis. The patient is relatively obese, and has a mother who weighs 200 pounds and a paternal grandmother with diabetes. Her pediatric endocrinologist predicted an adult height of less than 59 inches, which, based on mean parental heights, is more than two standard deviations below her target height. The patient had a bone age of five years and six months in October of 2004, as compared to her chronological age of six years and four months.

The patient is a 14-year-old male with short stature. His pre-GH height was 144 cm on 8/30/04, which was less than the third percentile and his pre-GH treatment height velocity was 5 cm a year. His bone age was reported as not delayed, being read at 13 years 8 months at a chronological age of 13 years 6 months. The IGF-1 result was 218. The patient had a peak GH level of 14 after clonidine and 9.8 after arginine. He was found to have testicular enlargement and to have entered puberty. His adult height prediction at 13 years 6 months approximates almost 5’2” to 5’3” at his then growth rate, according to the table in the Greulich and Pyle Hand Atlas.The patient began GH therapy in November 2004 at 0.4 mg/kg/week and showed an increased growth velocity of 7.44 cm per year.

Where the denial was upheld

The patient is a 12-year-old female with advanced sexual development who was projected to have short adult height. According to a note from a pediatric endocrinologist dated October 2005, when the patient was 4’10” at 11 years and 10 months she was to be given both Lupron Depot injections and growth hormone. The provider comments however in this note that “Unfortunately the growth hormone has not been very beneficial. She is considering using Humatrope. I don’t really believe that there will be a significant difference between the two medications.” He also comments that a recent bone age was 13 years and that the patient will likely not attain a height of 5’ without “immediate action.” The mid-parental height target was 5’3.5”. There is a cousin who had early puberty and became a 5’10” adult.

This case involves a 14-year-old male with idiopathic short stature. It does not appear GH stimulation testing has been performed. A brain MRI revealed a normal appearing pituitary. Recent serum levels of IGF-1 were normal for Tanner stage 4 of sexual development at 341. The projected adult height was 65 inches compared to a mid-parental height of 70.5 inches. Based upon the submitted records, it appears that the patient’s growth has always been just below the 3rd percentile. The submitted materials indicated GH was prescribed in June 2005. The endocrinologist noted that the patient had not had a pubertal growth spurt. After GH therapy, the summary indicates a growth velocity of 11.7 cm per year. The patient has requested authorization and coverage for growth hormone therapy.

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 Growth Hormone, then check the rights and deadlines that apply to your plan.