Ngenla — United Healthcare
Congenital Growth Hormone Deficiency (GHD)
Initial criteria
- Infant is < 12 months of age
- Evidence of growth failure confirmed by ALL of the following: (a) Growth charts for length/height and weight for age and gender with evidence of growth velocity deceleration over time; (b) Documentation of length/height and weight for age and gender including percentile and/or standard deviation scores; (c) Calculated growth velocity
- One of the following: (a) BOTH: (i) Hypothalmic-pituitary defect (e.g., ectopic posterior pituitary, empty sella, hypoplastic pituitary, major congenital malformation, optic nerve hypoplasia, tumor or irradiation) AND (ii) Deficiency of at least one additional pituitary hormone OR (b) ALL: (i) Neonatal hypoglycemia and/or micropenis, (ii) Serum GH concentration ≤ 5 μg/L in the first 28 days of life, (iii) Deficiency of at least one additional pituitary hormone, (iv) Classical imaging triad (ectopic posterior pituitary and pituitary hypoplasia with abnormal stalk)
- One of the following below the age and gender adjusted normal range as provided by the physician’s lab: (a) Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) OR (b) Insulin Growth Factor Binding Protein-3 (IGFBP-3)
Reauthorization criteria
- Height increase of at least 2 cm/year over the previous year documented by ALL of: (a) Previous length/height and date obtained; (b) Current length/height and date obtained; (c) Calculated growth velocity; (d) Growth chart for length/height for age and gender
- BOTH: (a) Expected adult height not attained AND (b) Documentation of expected adult height goal (e.g., genetic potential)