ZOMACTON — Blue Cross Blue Shield of Alabama

Initial criteria

• For adult GHD: documented pituitary or hypothalamic disease, panhypopituitarism, and subnormal serum IGF‑1 (below age‑ and gender‑specific lower limit of normal).
• Diagnosis without stimulation test allowed if: (1) organic hypothalamic‑pituitary disease with ≥3 pituitary hormone deficiencies and subnormal IGF‑1 (<‑2 SD), OR (2) genetic hypothalamic‑pituitary defects, OR (3) hypothalamic‑pituitary structural brain defects.
• For patients with ≤2 pituitary hormone deficiencies, one GH stimulation test required to confirm diagnosis.
• For transition patients (childhood‑onset GHD): after ≥1 month discontinuation, retest with provocation test if subnormal IGF‑1.
• For idiopathic childhood‑onset GHD with organic hypothalamic‑pituitary disease: at least one stimulation test required.
• For idiopathic short stature (ISS): height ≤‑2.25 SD (≤1.2 percentile) for age and sex; growth rate unlikely to reach normal adult range; epiphyses open; other causes excluded; not constitutional delay of growth and puberty.
• For ISS continuation: treatment maintained until linear growth <2.0–2.5 cm/year (≈1 in/year), corresponding to bone age 13–13.5 years in girls or 15.5–16 years in boys.
• For growth failure in CKD: all modifiable risk factors for growth impairment corrected AND growth impairment defined as height velocity (HV) for age <‑1.88 SD OR <3rd percentile.
• For short bowel syndrome (SBS): adult patients with SBS receiving specialized nutrition support.
• For small for gestational age (SGA): birth weight/length <‑2 SD below mean; no catch‑up growth by age 2 years (height remains <‑2 SD).
• For HIV wasting/cachexia: meets one or more of the following — 10% unintentional weight loss over 12 months; 7.5% over 6 months; >5% over 4 months; 5% body cell mass loss within 6 months; BMI < 20 kg/m²; men: BCM < 35% and BMI < 27 kg/m²; women: BCM < 23% and BMI < 27 kg/m².