CurrentUnitedHealthcarePolicy N/A

Human growth hormone (somatropin) — Washington Prior Authorization Request Form

Prior authorization form and requirements for coverage of human growth hormone (somatropin) for Washington Apple Health members; applies to prescribers requesting initiation or continuation of therapy for pediatric and adult indications including GHD, short bowel syndrome, HIV wasting, and other specified indications.

Policy Summary

PayerUnitedHealthcare

PolicyHuman growth hormone (somatropin) — Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the full prior authorization form to 866-940-7328 and allow at least 24 hours for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+form items to complete

24hminimum review time

866-940-7328submission fax

800-310-6826contact phone

Coverage Criteria for Human Growth Hormone (Somatropin)

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Initial therapy - Children and Adolescents

Covered when ALL of the following are met for children and adolescents (<18 years):

Pediatric initial: 1) Epiphyses are not closed (confirmed by radiograph of the wrist and hand) AND patient has not reached final height; 2) Diagnosis meets one of the listed pediatric indications: Prader-Willi syndrome; short stature associated with chronic renal insufficiency (dialysis or GFR <60 ml/min/1.73 m2) with height below the 5th percentile for age/sex and growth velocity below the 25th percentile for at least 1 year; short stature associated with Turner syndrome, Noonan syndrome, or SHOX gene deficiency with height below the 10th percentile; growth hormone deficiency (congenital GHD with supportive history such as hypoglycemia and low GH, or height below the 3rd percentile OR height below the 5th percentile with growth velocity below the 25th percentile for at least 1 year) ; idiopathic short stature or growth failure in children born small for gestational age (SGA) with height remaining >2.25 SD below the mean at age 2 or other specified criteria; 3) Diagnostic evidence per form: at least two GH stimulation tests below reference range OR one GH stimulation test below reference range with low IGF-1 and IGFBP-3 OR severely low IGF-1/IGFBP-3 (<-2 SD) with delayed bone age OR GHD with additional pituitary hormone deficiencies;see node text

Prescriber must attest that risks and benefits of growth hormone treatment have been discussed with patient and guardian(s).

Continuation therapy - Children and Adolescents

Covered for continuation when ALL of the following are met:

Pediatric continuation: Patient has shown a response to growth hormone therapy, defined as an increase in height or increase in height velocity as documented on the form.clinical response

Continuation section requests confirmation that patient demonstrated response to therapy.

Initial therapy - Adults

Covered when ONE of the following diagnostic pathways is documented for adults (18+):

Adult criteria group A: Documentation of three or more pituitary hormone deficiencies (e.g., TSH, ACTH, gonadotropins, ADH, etc.) together with a low IGF-1 level (<-2 standard deviation score).>=3 pituitary deficiencies

Meets adult GHD criteria per form.

Adult criteria group B: Documentation of childhood-onset GHD or GHD due to pituitary or hypothalamic disease, pituitary surgery, cranial radiation therapy, traumatic brain injury, or other condition affecting pituitary function.clinical history

Meets adult GHD criteria per form.

Adult criteria group C: Documented clinical features of GHD (for example osteopenia, increased cardiovascular risk, or decreased quality of life) with low IGF-1 (<0 SD) or other supportive findings.

Adult stimulation test criteria

Alternatively, covered when ALL of the following are documented:

Adult stimulation testing: Subnormal response to a provocative growth hormone stimulation test using accepted thresholds (e.g., macimorelin <2.8 ng/mL; insulin tolerance test (ITT) <5 ng/mL; glucagon stimulation test <3 ng/mL) and/or low IGF-1 with clinical features of GHD documented.test-specific cutoffs

Form specifies assay cutoffs for macimorelin, ITT, and glucagon-stimulation tests.

Continuation therapy - Adults

Covered for continuation when ONE of the following benefits is documented:

Adult continuation: Patient has shown clinical benefit from growth hormone replacement as assessed by normalization of IGF-1 or improvement in body composition (e.g., increased bone density, favorable changes in lipolysis).clinical or biochemical improvement

Form continuation criteria list normalization of IGF-1 or improvement in body composition as evidence of benefit.

Short bowel syndrome

Covered for short bowel syndrome when ALL of the following are met:

SBS initial: Patient is currently on specialized nutritional support that has been optimized for protein, calorie, and fluid intake for at least two weeks.>=2 weeks

Form requires documentation of at least two weeks of optimized nutritional support prior to GH therapy.

HIV/AIDS-associated wasting

Covered for HIV/AIDS-associated wasting when ALL of the following are met:

HIV wasting initial: Patient has been treated with an appetite stimulant (dronabinol or megestrol) that was ineffective, contraindicated, or not tolerated; prior somatropin therapy status is documented (including duration if prior therapy given); and for continuation, patient has demonstrated clinical benefit such as increase in muscle mass and weight.trial of appetite stimulant; documented benefit

Form asks whether appetite stimulant trial occurred and whether prior somatropin was received and documents clinical benefit for continuation.

No specific medical exclusions are listed on this prior authorization form. If the indication for somatropin is not one of the labeled choices on the form (for example, Growth Hormone Deficiency in children or adults, Short Bowel Syndrome, or HIV/AIDS-associated wasting), the provider must select “Other” and specify the diagnosis and clinically relevant rationale supporting medical necessity. Requests for non-listed indications should include supporting documentation sufficient to demonstrate that the requested use meets clinical criteria and justify coverage.

Key Coding and Thresholds

Predicted adult height threshold

Predicted adult height thresholdLess than 63 inches for males and less than 59 inches for females (adult height based on bone age)

ContextUsed when adult height, based on bone age, is expected to be below the normal range as part of pediatric/adolescent assessment

Documentation requiredProvider must attest that risks and benefits of growth hormone treatment have been discussed

Height percentile thresholds (children)

Height below 3rd percentileDefined as height below the 3rd percentile (more than 2 SDs for age and sex) — criterion for congenital GHD

Height below 5th percentileUsed for short stature associated with chronic renal insufficiency and as an alternative GHD criterion when accompanied by low growth velocity

Height below 10th percentileUsed for short stature associated with Turner syndrome, Noonan syndrome, or SHOX gene deficiency

IGF-1 abnormal thresholds

Low IGF-1 in children/adultsIGF-1 and IGFBP-3 severely low defined as <-2 SD (used in pediatric and adult diagnostic pathways)

Low IGF-1 adult featureLow IGF-1 level also referenced as <0 standard deviation score in adult clinical features of GHD

Role in diagnosisIGF-1 abnormality can support diagnosis when paired with stimulation testing or clinical features

Provider Instructions and Submission Requirements

Prior Authorization

Prior Authorization Required

Submit the completed Human Growth Hormone prior authorization form and fax to 866-940-7328. Allow at least 24 hours for review.

Fax completed form to 866-940-7328
Allow at least 24 hours for review
For questions call 800-310-6826

Documentation Required

Indication-specific completion

Complete the indication-specific sections of the prior authorization form that correspond to the patient's diagnosis. For pediatric and adult Growth Hormone Deficiency (GHD), ensure the form includes diagnostic testing, growth measures, and all supporting fields requested for the selected indication.

Children and adolescents (<18): complete questions 7–9, including epiphyseal status, final height status, diagnosis specifics (Prader‑Willi, chronic renal insufficiency, Turner/Noonan/SHOX, congenital GHD, SGA/idiopathic short stature) and required growth velocity/percentile data
Adults (≥18): complete questions 10–11, including documentation of pituitary hormone deficiencies, low IGF‑1, childhood‑onset GHD or GHD due to pituitary/hypothalamic disease, and results of GH stimulation testing if applicable
If request is for HIV/AIDS wasting or cachexia, complete the corresponding indication questions on the form

Documentation Required

Required documentation

Provide required documentation with the prior authorization request. Omission of these items may result in delay or denial.

Attach chart notes and baseline assessments (required)
Include baseline and current weight and height with dates
Include diagnostic test results as applicable (IGF‑1, IGFBP‑3, GH stimulation test results with numeric values and test type)
Document trials of preferred AHPDL growth hormone products with medication names and duration, or provide a rationale why preferred products are not suitable or not FDA‑approved for the indication
Prescriber signature, prescriber specialty, prescriber NPI, and date

Denial Risk

Missing documentation — risk of denial or delay

If the request does not include the required chart notes, baseline assessments, or completed indication‑specific sections, the request risks denial or will be delayed pending receipt of missing documentation.

Requests missing chart notes and baseline assessments may be denied or delayed
Incomplete indication-specific sections (e.g., missing growth measures or diagnostic test results) will delay review

OpenPayer

Human growth hormone (somatropin) — Washington Prior Authorization Request Form

Coverage Criteria for Human Growth Hormone (Somatropin)

Key Coding and Thresholds

Provider Instructions and Submission Requirements

Definitions and Diagnostic Thresholds

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