Somatropin — United Healthcare

Initial criteria

• Diagnosis of chronic renal insufficiency
• Growth charts show velocity deceleration; documentation of percentile/SD scores; calculated growth velocity
• Open epiphyses within last 12 months and Tanner stage ≤ 4
• Patient has not had a renal transplant
• Prescribed by an endocrinologist or nephrologist

Reauthorization criteria

• Height increase ≥ 2 cm/year over previous year with documented measurements and growth chart
• Expected adult height not attained and goal documented
• Patient has not had a renal transplant
• Prescribed by an endocrinologist or nephrologist

Approval duration

12 months