Growth Hormone (GH) in Children

somatropin (Humatrope®, Genotropin®, Norditropin®)

Indications for Prior Authorization:

  • Prader-Willi Syndrome
  • Turner’s Syndrome
  • Chronic renal insufficiency leading to growth failure (GFR <50 ml/min) up until renal transplant OR
  • Pediatric patients must be followed by a pediatric endocrinologist AND
  • (1) Meet criteria for Medical Necessity as follows:
    • Patient must have below normal response (less than 10 ng/ml) to any TWO of the following standard growth hormone tests:
      • GH Provocative Tests:
        • Insulin tolerance test
        • L-arginine
        • Clonidine
        • L-dopa
        • Glucagon
    • Must be performed within the last year
    • Peak value must be assessed using more than one time point (e.g. 0, 30, 60, 90, 120 minutes). OR
  • (2) Have at least TWO other pituitary hormone deficiencies in addition to IGF-1 measurement
    • IGF-1 below the reference ranges based on patient bone age. OR
  • (3) Hypoglycemia and clinical evidence of hypopituitarism AND at least one GH stimulation test is less than 10 ng/ml


  • Pediatric GHD: 0.16- 0.30 mg/kg/week given in 6-7 daily doses per wk
  • Chronic renal insufficiency: Nutropin & Nutropin AQ 0.35 mg/kg/wk SQ
  • Children-Pubertal Stage
  • A weekly dosage of 0.3 mg/kg divided into daily SC injection
  • A weekly dosage of up to 0.7 mg/kg divided daily may be used
  • (IGF-1 levels should be followed routinely in patients on the higher dose)
  • Turner Syndrome: 0.375 mg/kg/wk
  • Prader-Willi Syndrome 0.24 mg/kg/wk

Reauthorization of GH Therapy in children

  • Growth rate remains above 2.5 cm/year AND
  • For children over 13: X-ray documentation that the epiphyses have not yet closed

Termination of Therapy:

  • Bone age of 16 years for males or 14 years for females OR
  • The patient reaches an adult height at the 5th percentile (5'0" for females, 5'4" for males) and /or the growth velocity is <2.5cm/yr

Growth Hormone Therapy in Adults

  • Growth Hormone will considered Medically Necessary for the treatment of adults with documented hypopituitarism as a result of any of the following:
    • Pituitary disease
    • Hypothalamic disease
    • Surgery
    • Radiation therapy
    • Trauma
    • Subarachnoid hemorrhage
  • Coverage will be provided for patients with documented hypothalamic or pituitary disease who fail one GH stimulation test (< 10 ng/ml)
  • If a patient has multiple pituitary hormone deficiencies resulting from structural hypothalamic/pituitary disease, radiation, defined CNS pathology, cranial radiation, trauma, pituitary surgery, or genetic defect affecting the GH axis with low IGF-1 and low IGFBP-3, growth hormone can be approved
  • Patients with HIV disease that have lost greater than 10% of baseline weight (AIDS wasting syndrome) are candidates for GH therapy. Patients must be on antiviral therapy for HIV. Treatment will be authorized until patient no longer meets weight loss criteria

The following conditions do not meet criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Athletic performance enhancement
  • Anti aging factor
  • Burn injuries
  • Cardiomyopathy
  • Chronic catabolic states
  • Constitutional Delay in growth and development
  • Crohn’s Disease
  • Cystic fibrosis
  • Growth hormone treatment in combination with treatment (Lupron) for precocious puberty
  • Growth retardation due to:
    • Down Syndrome
    • Juvenile rheumatoid arthritis
  • Fibromyalgia
  • Hand-Schuller Christian Disease
  • Hyperinsulinism
  • Hypophosphatemic rickets
  • Idiopathic short stature
  • Idiopathic GHD with no history of GHD in childhood
  • Infertility
  • Kwashiorkor
  • Malnutrition
  • Muscular dystrophy
  • Obesity
  • Osteoporosis
  • Osteogenesis imperfecta
  • Skeletal dysplasias
  • “Somatopause” in older adults
  • Spina bifida


Last review date: December 2, 2013

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