somatropin — Medica
Short Stature Homeobox-Containing Gene Deficiency in a Child or Adolescent
Initial criteria
- Patient has short stature homeobox-containing gene deficiency demonstrated by chromosome analysis
- Epiphyses are open
- Baseline height < 5th percentile for age and gender
- Medication prescribed by or in consultation with an endocrinologist
Reauthorization criteria
- Patient is continuing somatropin therapy (established on somatropin for ≥ 10 months)
- Height has increased by ≥ 2 cm/year in the most recent year
- Patient’s epiphyses are open
Approval duration
1 year