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Nutropin — Highmark

Children with Chronic Kidney Disease (CKD)

Initial criteria

  • Diagnosis of CKD (ICD-10: N18) defined as GFR < 89 ml/min/1.73 m2.
  • Meets one (1) of: (a) growth velocity < 10th percentile over 12 months AND height between 2.25–2.5 SD below mean; OR (b) height ≥ 2.5 SD below mean.
  • Bone age ≤ 14 years (female) OR ≤ 16 years (male).

Reauthorization criteria

  • Clinical documentation of growth velocity ≥ 2 cm/year.
  • The member meets one (1) of the following: female with chronological age > 14 and bone age ≤ 14; male with chronological age > 16 and bone age ≤ 16; or female ≤ 14 years / male ≤ 16 years of age.