ALL of the following

• Pediatric: Growth Hormone Deficiency (GHD) - Biochemical criteria (ANY of the following):

  • Documentation of abnormal responses to two GH stimulation tests, defined as <10 ng/mL (or laboratory-defined cutoff).
  • At least one GH stimulation test <15 ng/mL AND both IGF-1 and IGFBP-3 levels below normal for age and gender.
  • One GH stimulation test <10 ng/mL in the setting of defined CNS pathology, history of cranial irradiation, or genetic conditions associated with GHD.
  • Two or more documented pituitary hormone deficiencies (other than GH).
  • Abnormally low GH level documented in association with neonatal hypoglycemia.

• Pediatric: Growth Hormone Deficiency - Auxologic/radiologic criteria (ALL of the following as applicable):

  • Height ≤ -2 standard deviations for age and gender; OR height ≤ -1 SD with growth velocity ≤ -1 SD for age and gender.
  • Either: (A) minimum of one year of growth data with measurements ≥6 months apart performed by an endocrinologist; OR (B) four or more height determinations measured ≥6 months apart by the primary care physician over at least two years demonstrating a consistent growth pattern.
  • Radiologic documentation of open growth plates in patients over 12 years of age (when applicable).

• Pediatric: Idiopathic/familial short stature or SGA with failure of catch-up growth by age 2 (ALL):

  • Height ≤ -2.25 standard deviations for age and gender measured per auxologic criteria above.
  • Growth velocity ≤ -1 SD for age and gender measured per auxologic criteria above.
  • Radiologic documentation of open growth plates in patients over 12 years of age (when applicable).

• Pediatric: Turner, Noonan, or Prader‑Willi syndromes (ALL):

  • Radiologic documentation of open growth plates in patients over 12 years of age (when applicable).
  • Height below the 10th percentile for age.

• Pediatric: Chronic renal insufficiency (ALL):

  • Creatinine clearance ≤75 mL/min/1.73 m2 OR serum creatinine >3.0 mg/dL OR dialysis dependence.
  • Radiographic documentation of open growth plates in patients over 12 years of age (when applicable).

• Pediatric: AIDS wasting (ALL):

  • Greater than 10% of baseline weight loss unexplained by concurrent illness other than HIV infection.
  • Concurrent treatment with antiviral agents.

• Pediatric: Burn patients (ANY of the following):

  • Extensive third-degree burns.
  • Burns ≥40% total body surface area.

• Pediatric: Short bowel syndrome (ALL):

  • Receiving specialized nutritional support.
  • Optimal medical/nutritional management of short bowel syndrome.

ALL of the following

• Measure serum IGF-1 two months after starting therapy to assess adequacy of treatment (no prior authorization required).
• Once IGF-1 is in normal range, repeat testing every 6 to 12 months (no prior authorization required).

ALL of the following

• Initial authorization: up to 12 months for indications meeting criteria; exception — burn patients: initial authorization up to 4 weeks.
• Continuation: may be approved in 12-month increments for many pediatric and adult indications with documentation (e.g., growth velocity ≥2 cm/year, open growth plates if >12 years, and height less than fifth percentile of normal adult height where specified).
• Continuation NOT approved: burn patients, AIDS wasting, and short bowel syndrome do not meet criteria for ongoing (continuation) authorization.

ALL of the following

• Therapy is covered only for listed indications when all specific criteria are met; uses outside these indications or without required documentation are excluded.

ALL of the following

• Serum IGF-1 testing at two months after initiation and every 6–12 months thereafter when normalized is covered and does not require prior authorization.

ALL of the following

• Prior authorization is required for GH therapy; requests must be submitted via UHA's online portal. If login has not been established, contact UHA at 808-532-4000 to establish one.
• Initial and continuation authorizations are issued per the durations and documentation requirements specified above; some indications have specific administrative restrictions on continuation (see authorization durations and continuation restrictions).