Somatropin — United Healthcare

Initial criteria

• Diagnosis of Prader-Willi Syndrome confirmed by genetic testing
• AND one of the following: (a) BOTH patient is <18 years AND evidence of growth failure confirmed by growth charts, documentation of length/height and weight for age/sex, and calculated growth velocity OR (b) patient is >18 years of age
• AND patient does NOT have: (a) Active malignancy; (b) Severe obesity (weight >225% of ideal body weight); (c) Severe respiratory impairment

Reauthorization criteria

• ONE of the following: (a) For patients <18 years: Height increase ≥2 cm/year over previous year documented by prior and current height data, growth velocity, and growth charts AND BOTH expected adult height not attained AND documentation of expected adult height goal OR (b) For patients ≥18 years: Documentation of positive response to therapy (reduction in fat mass, increase in lean body mass, improved strength/exercise tolerance)

Approval duration

12 months