Growth Hormone Deficiency:
Duration: 12 Month(s)
Specialist Required: Yes
Specialist Type(s): Endocrinologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 3 of Bone Age Required;Delayed Skeletal Maturation Required;Diagnosis of Pediatric Growth Hormone Deficiency;Growth velocity is > 2 standard deviations below mean for age and gender;Growth Velocity Required;Height is > 2.25 standard deviations below population mean (< 1.2 percentile for age and gender) utilizing age and gender growth charts;History of Neonatal Hypoglycemia Required;Tanner stage < 4
Pediatric - GH Stimulation Test: = 2
Pediatric - Pituitary Hormone Deficiency: Unspecified
Pediatric - Reauthorization Requirement(s): 3 of Expected adult height has not been reached;Height has increased by >= 2 cm/year in the most recent year;Other requirement(s)
Adult Growth Hormone Deficiency Requirement(s): 4 of Cannot be used in combination with Androgens;Cannot be used in combination with Aromatase Inhibitors;Diagnosis of Adult-onset Growth Hormone Deficiency (GHD);Diagnosis of Childhood-onset Growth Hormone Deficiency (GHD);Documentation of peak GH level;Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
Adult - GHD Stimulation Test: = 1
Adult - Pituitary Hormone Deficiency: = 3
Adult - Duration of Initial Authorization: = 12 month(s)
Adult - Reauthorization Requirement(s): 2 of Diagnosis of panhypopituitarism;Insulin-like Growth Factor 1 (IGF-1) Required;Other requirement(s)
Adult - Duration of Reauthorization: = 12 month(s)
Documented Diagnosis of Other Approved Indications: 1 of Chronic Renal Insufficiency;Growth Failure in Children Born Small for Gestational Age (SGA);Prader-Willi Syndrome in Children (PWS);Short Stature Homeobox-Containing Gene (SHOX);Turner's Syndrome (TS)
Documented Diagnosis: Yes