Somatropin — United Healthcare

Adult Growth Hormone Deficiency

Initial criteria

Diagnosis of adult growth hormone deficiency (GHD) as a result of ONE of: (a) Known hypothalamic or pituitary disease; (b) Panhypopituitarism; (c) History of GHD in childhood
AND one of the following: (a) IGF-1 level below the age/gender adjusted normal range per physician lab OR (b) ALL of: (i) Patient does not have low IGF-1; (ii) Patient has undergone GH stimulation test (GHRH+ARG, Glucagon, or Macimorelin); (iii) Peak GH value at or below test thresholds (GHRH+ARG ≤11 µg/L; Glucagon ≤3 ng/mL; Macimorelin ≤2.8 ng/mL)
AND one of the following: (a) Diagnosis of panhypopituitarism OR (b) Other diagnosis AND not used with aromatase inhibitors (Arimidex, Femara) OR androgens (Delatestryl, Depo-Testosterone)

Documentation of IGF-1 within past 12 months
AND one of the following: (a) Diagnosis of panhypopituitarism OR (b) Other diagnosis AND not used with aromatase inhibitors (Arimidex, Femara) OR androgens (Delatestryl, Depo-Testosterone)

12 months