A review of the records reveals the member to be a young male with a birth date of 12/31/02. The member has a diagnosis of Idiopathic Short Stature (ISS). His provider, Earline Edwards, APRN has recommended Omnitrope 10 mg/1.5 ml, 12 units from 01/26/16-01/25/17.
The carrier has denied coverage of Omnitrope 10 mg/1.5 ml, 12 units from 01/26/16-01/25/17 as not medically necessary. There is a letter to the member from the carrier dated 01/21/16. In the letter, the carrier states in part: “Your request for coverage of Omnitrope 10mg/1.5 ML has been denied. Your request does not meet the requirements for coverage under your pharmacy benefit. Medica’s guideline for Growth Hormone (somatropin) is not covered for situations such as idiopathic short stature where there is no clinical evidence of a growth hormone deficiency.”
Discussion of Findings:
The patient is an approximately 13 year old male with 22q11 deletion. He “passed” one and “failed” one provocative …show more content…
This is an indication of a response to the growth hormone therapy. While this is not the predominant reason growth hormone is administered, it is critical in children with muscle tone so poor that it inhibits basic daily activities, normal interaction with the world around them, and with the ability to achieve motor milestones. This is not about an athlete seeking “super” strength. This is about a child literally flaccid without the ability to hold his head upright, or walk without assistance, or hold utensils. I have several patients who were incapable of interacting with their environment, unable to walk, who upon treatment with growth hormone not only grew taller, but the increase in lean body mass allowed them to gain control over their bodies, walk for the first time, navigate (even if in a wheelchair), etc. This is a very legitimate reason to treat with growth hormone, and a known physiological action of the
The carrier has denied coverage of Omnitrope 10 mg/1.5 ml, 12 units from 01/26/16-01/25/17 as not medically necessary. There is a letter to the member from the carrier dated 01/21/16. In the letter, the carrier states in part: “Your request for coverage of Omnitrope 10mg/1.5 ML has been denied. Your request does not meet the requirements for coverage under your pharmacy benefit. Medica’s guideline for Growth Hormone (somatropin) is not covered for situations such as idiopathic short stature where there is no clinical evidence of a growth hormone deficiency.”
Discussion of Findings:
The patient is an approximately 13 year old male with 22q11 deletion. He “passed” one and “failed” one provocative …show more content…
This is an indication of a response to the growth hormone therapy. While this is not the predominant reason growth hormone is administered, it is critical in children with muscle tone so poor that it inhibits basic daily activities, normal interaction with the world around them, and with the ability to achieve motor milestones. This is not about an athlete seeking “super” strength. This is about a child literally flaccid without the ability to hold his head upright, or walk without assistance, or hold utensils. I have several patients who were incapable of interacting with their environment, unable to walk, who upon treatment with growth hormone not only grew taller, but the increase in lean body mass allowed them to gain control over their bodies, walk for the first time, navigate (even if in a wheelchair), etc. This is a very legitimate reason to treat with growth hormone, and a known physiological action of the