CurrentUnitedHealthcarePolicy N/A

Nc Growth Hormone Adult Pa Form

This document is a prior authorization request form for growth hormone therapy (adult and pediatric indications) used by UnitedHealthcare (North Carolina). It collects beneficiary, prescriber, drug, and clinical information to support coverage decisions, including diagnosis, prior medication trials, growth hormone deficiency testing, and specific condition checkboxes.

Policy Summary

PayerUnitedHealthcare

PolicyNc Growth Hormone Adult Pa Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective Date

Next Review Date

Key ActionProvider must complete and sign the form including beneficiary, prescriber, drug, diagnosis, clinical history, biochemical and stimulation test results, and prescriber signature to support PA review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

1Form pages/sections

MultipleClinical evidence fields required

Form purpose and scope

This is a UnitedHealthcare (North Carolina) prior authorization request form for growth hormone therapy (adult and pediatric indications). It is a structured administrative form used to collect beneficiary identifying information, prescriber contact and NPI, drug name/strength/quantity and length of therapy selection, diagnosis, clinical history checkboxes (e.g., Turner syndrome, Prader-Willi, craniopharyngioma, hypopituitarism, cranial irradiation, chronic renal insufficiency, SGA/IUGR), and Zorbitive‑specific short bowel syndrome history.

The form gathers clinical and laboratory evidence elements the payer uses to determine medical necessity rather than stating coverage rules. Required clinical data fields include growth metrics (current height, percentile, height velocity for bone age with < 25th Percentile threshold), birth weight/length criterion (more than 2 standard deviations below mean (≤ -2 SD)), short stature thresholds (height < 3rd percentile and > 2.25 SD below mean for age), bone age (> 2 SD below mean), biochemical data (IGF‑1 and IGFBP‑3 levels), and GH stimulation test documentation including agents and peak ng/ml values to indicate GHD.

For non‑preferred drugs the form requires either documentation of failure of two preferred drugs (with drugs listed) or a stated reason why the patient cannot try two preferred agents. The prescriber must sign and date the form (signature mandatory) to certify the accuracy of the information for payer review.

Key Metadata

PayerUnitedHealthcare

PolicyNC Growth Hormone Adult PA Form

Document typeadministrative

StatusCURRENT

Scope summaryThis document is a prior authorization request form for growth hormone therapy (adult and pediatric indications) used by UnitedHealthcare (North Carolina). It collects beneficiary, prescriber, drug, and clinical information to support coverage decisions, including diagnosis, prior medication trials, growth hormone deficiency testing, and specific condition checkboxes.

Form pages/sections1

Clinical evidence fields requiredMultiple (e.g., beneficiary, prescriber, drug, diagnosis, growth metrics, IGF-1/IGFBP-3, GH stimulation test, condition checkboxes)

Required clinical and laboratory fields on the form

Form Fields for Clinical Criteria / Eligibility Evidence

Request must supply completed items and checkboxes; these represent evidence elements used by the payer to determine medical necessity.

ALL of the following

Beneficiary information: Beneficiary identifying information completed (last name, first name, beneficiary ID, DOB, gender).
Prescriber information completed (Prescribing Provider NPI, requester contact name and phone).
Drug information completed (Drug name, strength, quantity per 30 days, length of therapy selection).
Length of therapy choices (up to 30, 60, 90, 120, 180, 365 days).
Diagnosis provided on the form.
FOR NON-PREFERRED DRUGS: either
- Failed preferred drugs: Documentation of failure of two preferred drugs with list of preferred drugs failed.
- Reason for not trying preferred drugs: Documented reason why patient cannot try two preferred drugs.
History checkboxes completed as applicable (Turner syndrome, Prader-Willi syndrome, craniopharyngioma, panhypopituitarism, cranial irradiation, MRI history of hypopituitarism, hypopituitarism, chronic renal insufficiency, SGA with IUGR, other).
If pediatric-onset considerations
- Child diagnosis status: Was the patient diagnosed as a child? (Yes/No)
- Adequately nourished child with hypoglycemia: Was the patient an adequately nourished child with hypoglycemia and a low GH response to hypoglycemia? (Yes/No)
- Treated childhood GHD with low IGF-1: Is the patient currently being treated and diagnosed with GHD in childhood with a current low IGF-1? (Yes/No)IGF-1 Level
  Form requests IGF-1 Level when applicable.
- Short stature childhood criteria: Is the patient currently being treated and diagnosed with short stature in childhood with height > 2.25 standard deviations below mean for age, bone age > 2 standard deviations below mean and low serum IGF-1 and IGFBP3? (Yes/No)
Growth/height metrics and percentiles documented where requested (height velocity <25th percentile for bone age question with height velocity field; current height and percentile; birth weight/length <= -2 SD with no catch up by age 2 question).Height velocity for bone age: < 25th Percentile; Height for age (child): < 3rd percentile; Birth weight/length: <= -2 SD
Height, percentile and height velocity fields on form.
Biochemical evidence: IGF-1 and IGFBP-3 levels documented where requested.IGF-1 and IGFBP-3 laboratory levels (numeric fields)
IGF-1 and IGFBP-3 fields present on form.
GH stimulation testing: documentation whether GHD documented by a negative response to a GH stimulation test (Yes/No), with agents and peak ng/ml recorded.GH stimulation test peak: document peak ng/ml
Agent 1, Agent 2 and peak Ng/ml fields requested.
Cause of GHD documented (pituitary/hypothalamic disease, radiation, surgery, trauma).
Zorbitive-specific: Zorbitive only: history of short bowel syndrome in the last 2 years documented (Yes/No).History within last 2 years
Zorbitive indication requires short bowel syndrome history within 2 years.
Prescriber signature and date (mandatory).
Prescriber signature mandatory on form.

Thresholds

Height velocity for bone age< 25th Percentile

Height for age (child)< 3rd percentile

Birth weight/lengthmore than 2 standard deviations below mean for gestational age (<= -2 SD)

Short stature metric (child)> 2.25 standard deviations below mean for age

Bone age> 2 standard deviations below mean

GH stimulation test peakdocumented peak ng/ml (negative response indicates GHD)

What the provider must supply

Prior Authorization

Submit completed prior authorization form

Provider must complete and sign the form including beneficiary, prescriber, drug, diagnosis, clinical history, biochemical and stimulation test results, and prescriber signature to support PA review.

Beneficiary (last name, first name, beneficiary ID, DOB, gender)
Prescriber (NPI, requester contact name and phone)
Drug (name, strength, quantity per 30 days, length of therapy)
Diagnosis
Clinical history
Biochemical and stimulation test results
Prescriber signature and date

Documentation Required

Document prior medication trials for non-preferred agents

For non-preferred drugs, document failure of two preferred drugs or state reasons why the patient cannot try two preferred drugs.

Document failure of two preferred drugs and list the preferred drugs failed
Or provide reason why the patient cannot try two preferred drugs

Documentation Required

Provide growth and laboratory data

Provide height, percentiles, height velocity for bone age, IGF-1 and IGFBP-3 levels, and GH stimulation test agents and peak values as indicated on the form.

Current height and percentile
Height velocity (for bone age) and whether < 25th percentile
IGF-1 level
IGFBP-3 (IGF-BP3) level
GH stimulation test agents and peak ng/ml values

Documentation Required

Zorbitive indication documentation

For Zorbitive requests, document history of short bowel syndrome within the last 2 years.

Confirm history of short bowel syndrome in the last 2 years (Yes/No)

Key terms on the form

Term	Definition
GHD
Growth hormone deficiency; documentation may include GH stimulation testing or other clinical/biochemical evidence.

Document dates and revisions

StatusLatest

CURRENT - administrative PA form; no dated revision history provided

Policy Summary

PayerUnitedHealthcare

PolicyNc Growth Hormone Adult Pa Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective Date

Next Review Date

SourceLink

On This Page

IGF-1 Level; IGFBP-3 Level

Form requests IGF-1 and IGFBP-3 levels when applicable.