Human Growth Hormone

Policy ID: I-9012-005

Section: Injections

Effective Date: January 01, 2021

Revised Date: November 13, 2023

Revision Effective Date: December 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial Only

Description

Exogenous human growth hormone is a recombinant polypeptide hormone. Human growth hormone plays a role in stimulating skeletal, connective tissue, muscle, and organ growth in children and adolescents, as well as metabolism in adults.

Recombinant growth hormone products are considered clinically identical, with no evidence that one commercial product is different or more advantageous than another, apart from differences in how the Growth Hormone product is stored, dosed, and administered by device. Therefore, one commercial Growth Hormone product is not recommended over another because there are no prospective head-to-head trials comparing the clinical efficacy of one commercial product with another.

Human growth hormone is a self-administered medication and is covered under the pharmacy benefit.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

Preferred Agents

Short-Acting Growth Hormone
Genotropin^®, Genotropin^® MiniQuick (somatropin)
Norditropin^® FlexPro^® (somatropin)
Omnitrope^® (somatropin)

Nonpreferred Agents

Short-Acting Growth Hormone
Humatrope^®, Humatropen^® (somatropin)
Nutropin AQ^® NuSpin^® (somatropin)
Saizen^®, saizenprep^® (somatropin)
Serostim^® (somatropin)
Zomacton^® (somatropin)
Zorbtive^® (somatropin)

Long-Acting Growth Hormone
Ngenla (somatrogon-ghla)
Skytrofa^® (lonapegsomatropin-tcgd)
Sogroya (somapacitan-beco)

Human Growth Hormone should be billed through a member's pharmacy benefit but may be considered medically necessary to bill through a member's medical benefit if the following criteria is met:

ONE of the following:
- The individual is receiving the human growth hormone for training and education purposes; or
- The individual's primary insurance requires medical claim processing; or
- A medical reason is provided as to why an individual cannot self-administer (i.e., physical disability, anxiety/panic attack, previous severe reaction to the human growth hormone; or
- The individual is hospitalized; and
The individual must also meet the below specific criteria for the requested product for a child or adult (as defined by the prescriber).

The use of human growth hormone for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

J2941

J3590

SHORT-ACTING GROWTH HORMONE

Children - Initial Criteria

Short-acting human growth hormone may be considered medically necessary in the treatment of children when ALL of the following are met:

The individual is a child (as defined by the prescriber); and
The individual has ONE of the following diagnoses:
- The individual is a newborn (less than or equal to four (4) months of age) with hypoglycemia AND serum growth hormone (GH) concentration less than or equal to 5 mcg/L AND at least ONE of the following:
  1. Congenital pituitary abnormality (e.g., ectopic posterior pituitary and pituitary hypoplasia with abnormal stalk); or
  2. Deficiency of at least one additional pituitary hormone; or
- The individual is a newborn (less than or equal to four (4) months of age) with hypoglycemia AND growth hormone (GH) concentration less than 20 mcg/L AND BOTH of the following:
  1. The individual does not have a known metabolic disorder; and
  2. The individual has a reduced IGFBP-3 level (e.g., less than -2 SD); or
- The individual has a diagnosis of Turner syndrome; or
- The individual has a diagnosis of Noonan syndrome; or
- The individual has a diagnosis of Prader-Willi syndrome; or
- The individual has a diagnosis of SHOX gene deficiency; or
- The individual has a diagnosis of short bowel syndrome (SBS) AND is receiving specialized nutritional support AND ONE of the following:
  - The individual's age is within FDA labeling for the requested indication for the requested agent; or
  - The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; or
- The individual has a diagnosis of panhypopituitarism or has deficiencies in at least three (3) or more pituitary axes AND serum IGF-I levels below the age- and sex-appropriate reference range when off GH therapy; or
- The individual has a diagnosis of chronic renal insufficiency and BOTH of the following:
  1. The individual's height velocity (HV) for age is less than -1.88 standard deviations (SD) OR HV for age is less than the third percentile; and
  2. Other etiologies for growth impairment have been addressed; or
- The individual has a diagnosis of small for gestational age (SGA) and ALL of the following:
  1. The individual is two (2) years of age or older; and
  2. The individual has a documented birth weight and/or birth length that is two (2) or more standard deviations (SD) below the mean for gestational age; and
  3. At 24 months of age, the individual failed to manifest catch-up growth evidenced by a height that remains two (2) or more standard deviations (SD) below the mean for age and sex; or
- The individual has a diagnosis of idiopathic short stature (ISS) AND ALL of the following:
  - The individual has a height less than or equal to -2.25 SD below the corresponding mean height for age and sex; and
  - The individual has open epiphyses; and
  - ONE of the following:
    - The individual has a predicted adult height that is below the normal range AND ONE of the following:
      - The individual's sex is male and predicted adult height is less than 63 inches; or
      - The individual's sex is female and predicted adult height is less than 59 inches; or
    - The individual is more than two (2) SD below their mid-parental target height; and
  - BOTH of the following:
    - The individual has been evaluated for constitutional delay of growth and puberty (CDGP); and
    - The individual does NOT have a diagnosis of CDGP; or
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  1. The individual has extreme short stature (e.g., height less than or equal to -3 SD), normal nutrition, significantly reduced IGF-1 and IGFBP-3 (e.g., less than -2 SD), and delayed bone age; or
  2. BOTH of the following:
    1. The individual has ONE of the following:
      1. Height more than two (2) SD below the mean for age and sex; or
      2. Height more than 1.5 SD below the midparental height; or
      3. A decrease in height SD of more than 0.5 over one year in children greater than two (2) years of age; or
      4. Height velocity (HV) more than two (2) SD below the mean over one year or more than 1.5 SD sustained over two (2) years; or
      5. Height-for-age curve that has deviated downward across two major height percentile curves (e.g., from above the 25^th percentile to below the 10^th percentile); or
      6. BOTH of the following:
        
        The individual's age is 2-4 years; and
        The individual has a HV less than 5.5 cm/year (less than 2.2 inches/year); or
      7. BOTH of the following:
        
        The individual's age is 4-6 years; and
        The individual has a HV less than 5 cm/year (less than 2 inches/year); or
      8. The individual's age is six (6) years to puberty AND ONE of the following:
        
        The individual's sex is male and HV is less than 4 cm/year (less than 1.6 inches/year); or
        
        The individual's sex is female and HV is less than 4.5 cm/year (less than 1.8 inches/year); and
    2. ONE of the following:
      1. The individual has failed at least two (2) GH stimulation tests (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab); or
      2. The individual has failed at least one (1) GH stimulation test (e.g., peak GH value of < 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab) AND ONE of the following:
        
        Pathology of the central nervous system; or
        History of irradiation; or
        Other pituitary hormone defects (e.g., multiple pituitary hormone deficiency [MPHD]); or
        A genetic defect; or
      3. The individual has a pituitary abnormality and a known deficit of at least one other pituitary hormone; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
ONE of the following:
- The request is for a preferred agent; or
- The request is for a nonpreferred agent and ONE of the following:
  1. The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  2. The prescriber has provided information to support the efficacy of the requested nonpreferred agent over a preferred agent for the intended diagnosis (medical record required).

The use of short- acting human growth hormone for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

J2941

Children - Reauthorization Criteria

Short-acting human growth hormone may be considered medically necessary in the treatment of children when ALL of the following are met:

The individual has been previously approved for therapy with GH through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- The request is for a preferred agent; or
- The request is for a nonpreferred agent and ONE of the following:
  1. The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  2. The prescriber has provided information to support the efficacy of the requested nonpreferred agent over a preferred agent for the intended diagnosis (medical record required); and
ONE of the following:
- The individual has a diagnosis of short bowel syndrome (SBS) AND has had clinical benefit with the requested agent AND ONE of the following:
  - The individual's age is within FDA labeling for the requested indication for the requested agent; or
  - The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; or
- The individual has a diagnosis of ISS and BOTH of the following:
  - Growth velocity is greater than two (2) cm/year; and
  - Bone age is less than 16 years in individuals with a sex of male and 15 years in individuals with a sex of female AND the individual has open epiphyses; or
- The individual has any other diagnosis AND ALL of the following:
  1. The individual does not have closed epiphyses; and
  2. The individual's height has increased or height velocity has improved since initiation or last GH approval; and
The individual is being monitored for adverse effects of GH; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis.

Procedure Codes

J2941

LONG-ACTING GROWTH HORMONE

Children - Initial Criteria

Long-acting human growth hormone may be considered medically necessary in adults when ALL of the following are met:

ONE of the following:
- The individual has an FDA approved indication for the requested agent; or
- The individual has another indication that is supported in compendia for the requested agent and route of administration; and
ONE of the following:
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  - The individual has extreme short stature (e.g., height less than or equal to -3 SD), normal nutrition, significantly reduced IGF-1 and IGFBP-3 (e.g., less than -2 SD), and delayed bone age; or
  - BOTH of the following:
    1. The individual has ONE of the following:
      1. Height more than two (2) SD below the mean for age and sex; or
      2. Height more than 1.5 SD below the midparental height; or
      3. A decrease in height SD of more than 0.5 over one year in children greater than two (2) years of age; or
      4. Height velocity (HV) more than two (2) SD below the mean over one year or more than 1.5 SD sustained over two years; or
      5. Height-for-age curve that has deviated downward across two major height percentile curves (e.g., from above the 25^th percentile to below the 10^th percentile); or
      6. BOTH of the following:
        
        The individual's age is 2-4 years; and
        The individual has a HV less than 5.5 cm/year (less than 2.2 inches/year); or
      7. BOTH of the following:
        
        The individual's age is 4-6 years; and
        The individual has a HV less than 5 cm/year (less than 2 inches/year); or
      8. The individual's age is six (6) years to puberty AND ONE of the following:
        
        The individual's sex is male and HV is less than 4 cm/year (less than 1.6 inches/year); or
        The individual's sex is female and HV is less than 4.5 cm/year (less than 1.8 inches/year); and
    2. ONE of the following:
      1. The individual has failed at least two (2) GH stimulation tests (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab); or
      2. The individual has failed at least one (1) GH stimulation test (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab) AND ONE of the following:
        
        Pathology of the central nervous system; or
        History of irradiation; or
        Other pituitary hormone defects (e.g., multiple pituitary hormone deficiency [MPHD]); or
        A genetic defect; or
      3. The individual has a pituitary abnormality and a known deficit of at least one other pituitary hormone; or
- The individual has another FDA approved or compendia supported indication for the requested agent and route of administration; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- The individual's age is within FDA labeling for the requested indication for the requested agent; or
- The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; and
ONE of the following:
- BOTH of the following:
  - The individual has received a trial of a preferred short-acting GH for at least 12 months (medical record required); and
  - The individual has failed to achieve a two (2) cm/year growth velocity due to lack of adherence to a preferred short-acting GH (medical record required); or
- The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent (medical record required); and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual does NOT have any FDA labeled contraindications to the requested agent.

The use of long- acting human growth hormone for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

J3590

Children - Reauthorization Criteria

Long-Acting Growth Hormone Agent(s) will be approved when ALL of the following are met:

The individual has been approved for therapy with GH previously through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- BOTH of the following:
  1. The individual has received a trial of a preferred short-acting GH for at least 12 months (medical record required); and
  2. The individual has failed to achieve a two (2) cm/year growth velocity due to lack of adherence to a preferred short-acting GH (medical record required); or
- The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent (medical record required); and
ONE of the following:
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND BOTH of the following:
  1. The individual does NOT have closed epiphyses; and
  2. The individual's height has increased or height velocity has improved since initiation or last GH approval; or
- BOTH of the following:
  1. The individual has another FDA approved or compendia supported indication for the requested agent and route of administration; and
  2. The individual has had clinical benefit with the requested agent; and
The individual is being monitored for adverse effects of GH; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual does NOT have any FDA labeled contraindications to the requested agent.

Procedure Codes

J3590

Adults - Initial Criteria

Human growth hormone may be considered medically necessary in the treatment of adults when ALL of the following are met

The individual is an adult (as defined by the prescriber); and
The individual has ONE of the following diagnoses:
- The individual has a diagnosis of AIDS wasting/cachexia AND ALL of the following:
  - The requested agent is a short acting growth hormone; and
  - The individual is currently treated with antiretroviral therapy; and
  - The individual will continue antiretroviral therapy in combination with the requested agent; and
  - BOTH of the following:
    1. ONE of the following:
      1. The individual has had weight loss that meets ONE of the following:
        
        10% unintentional weight loss over 12 months; or
        7.5% unintentional weight loss over six (6) months; or
      2. The individual has a body cell mass (BCM) loss greater than or equal to five (5)% within six (6) months; or
      3. The individual's sex is male and has BCM less than 35% of total body weight and body mass index (BMI) less than 27 kg/m²; or
      4. The individual's sex is female and has BCM less 23% of total body weight and BMI less 27 kg/m²; or
      5. The prescriber has provided information that the individual's BCM less than 35% or less than 23% and BMI less than 27 kg/m² are medically appropriate for diagnosing AIDS wasting/cachexia for the individual's sex; or
      6. The individual's BMI is less than 20 kg/m²; and
    2. All other causes of weight loss have been ruled out; or
- The individual has a diagnosis of short bowel syndrome (SBS) AND BOTH of the following:
  - The requested agent is a short acting growth hormone; and
  - The individual is receiving specialized nutritional support; or
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  1. The individual had a diagnosis of childhood-onset growth hormone deficiency AND has failed at least one (1) growth hormone (GH) stimulation test as an adult; or
  2. The individual has a low insulin-like growth factor-1 (IGF-1) level AND ONE of the following:
    1. Organic hypothalamic-pituitary disease; or
    2. Pituitary structural lesion or trauma; or
    3. The individual has panhypopituitarism or multiple (greater than or equal to three (3)) pituitary hormone deficiency; or
  3. The individual has an established causal genetic mutation OR hypothalamic-pituitary structural defect other than ectopic posterior pituitary; or
  4. The individual has failed at least two (2) growth hormone (GH) stimulation tests as an adult; or
  5. The individual has failed at least one (1) GH stimulation test as an adult AND the individual has an organic pituitary disease; and
- The individual has another FDA approved indication for the requested agent and route of administration; or
- The individual has another indication that is supported in compendia for the requested agent and route of administration; and
The request is for a long-acting agent AND if the individual has an FDA approved indication, then ONE of the following:
- The individual's age is within FDA labeling for the requested indication for the requested agent; or
- The prescriber has provided information in support of using the requested agent for the patient's age for the requested indication; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis; and
If the request is for a short acting GH agent, then ONE of the following:
- The request is for a preferred agent; or
- If the request is for a nonpreferred agent, ONE of the following:
  - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over a preferred agent for the intended diagnosis (medical record required); or
If the request is for a long acting GH agent, then BOTH of the following:
- The nonpreferred agent is supported in FDA labeling for the requested indication; and
- ONE of the following:
  - The preferred agent is not supported in FDA labeling for the requested indication; or
  - ONE of the following:
    - The individual has received a trial of a preferred short acting GH agent for at least 12 months; or
    - The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent.

Procedure Codes

J2941

J3590

Adults - Reauthorization Criteria

Human growth hormone may be considered medically necessary in adults when ALL of the following are met:

The individual has been approved for therapy with GH previously through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is an adult (as defined by the prescriber); and
ONE of the following:
- The requested agent is a short-acting agent AND ONE of the following:
  - The request is for a preferred agent; or
  - The request is for a nonpreferred agent AND ONE of the following:
    - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
    - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over a preferred agent for the intended diagnosis (medical record required); or
- The request is for a long-acting growth hormone agent AND BOTH of the following:
  - The nonpreferred agent is supported in FDA labeling for the requested indication; and
  - ONE of the following:
    - The preferred agent is not supported in FDA labeling for the requested indication; or
    - ONE of the following:
      - The individual has received a trial of a preferred short acting GH agent for at least 12 months; or
      - The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent.
ONE of the following:
- The individual has a diagnosis of short bowel syndrome (SBS) AND has had clinical benefit with the requested agent; or
- The individual has a diagnosis of AIDS wasting/cachexia AND ALL of the following:
  1. The individual is currently treated with antiretroviral therapy; and
  2. The individual will continue antiretroviral therapy in combination with the requested agent; and
  3. The individual has had clinical benefit with the requested agent (i.e., an increase in weight or weight stabilization); or
- The patient has growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND BOTH of the following:
  - The individual's IGF-I level has been evaluated to confirm the appropriateness of the current dose; and
  - The individual has had clinical benefit with the requested agent (i.e., body composition, hip-to-waist ratio, cardiovascular health, bone mineral density, serum cholesterol, physical strength, or quality of life); or
- The individual has a diagnosis other than SBS, AIDS wasting/cachexia, GHD, or growth failure due to inadequate secretion of endogenous growth hormone AND has had clinical benefit with the requested agent; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual is being monitored for adverse effects of GH.

Procedure Codes

J2941

J3590

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

NOTE: Compendia Allowed: DrugDex 1 or 2a level of evidence

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J2941

B20

C75.1

C75.2

C79.9

D33.0

D33.1

D33.2

D35.2

D35.3

D44.3

D44.4

D49.7

E23.0

E23.1

E23.3

E23.6

E23.7

E34.30

E34.31

E34.328

E34.329

E34.39

E89.3

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

N18.9

N25.0

P05.10

P05.11

P05.12

P05.13

P05.14

P05.15

P05.16

P05.17

P05.18

P05.19

Q85.00

Q85.01

Q85.02

Q85.03

Q85.09

Q85.9

Q87.11

Q87.19

Q87.5

Q96.0

Q96.1

Q96.2

Q96.3

Q96.4

Q96.8

Q96.9

R62.0

R62.50

R62.51

R64

T20.30XA

T20.30XD

T20.30XS

T20.311A

T20.311D

T20.311S

T20.312A

T20.312D

T20.312S

T20.319A

T20.319D

T20.319S

T20.33XA

T20.33XD

T20.33XS

T20.34XA

T20.34XD

T20.34XS

T20.35XA

T20.35XD

T20.35XS

T20.36XA

T20.36XD

T20.36XS

T20.37XA

T20.37XD

T20.37XS

T20.39XA

T20.39XD

T20.39XS

T22.30XA

T22.30XD

T22.30XS

T22.311A

T22.311D

T22.311S

T22.312A

T22.312D

T22.312S

T22.319A

T22.319D

T22.319S

T22.321A

T22.321D

T22.321S

T22.322A

T22.322D

T22.322S

T22.329A

T22.329D

T22.329S

T22.331A

T22.331D

T22.331S

T22.332A

T22.332D

T22.332S

T22.339A

T22.339D

T22.339S

T22.341A

T22.341D

T22.341S

T22.342A

T22.342D

T22.342S

T22.349A

T22.349D

T22.349S

T22.351A

T22.351D

T22.351S

T22.352A

T22.352D

T22.352S

T22.359A

T22.359D

T22.359S

T22.361A

T22.361D

T22.361S

T22.362A

T22.362D

T22.362S

T22.369A

T22.369D

T22.369S

T22.391A

T22.391D

T22.391S

T22.392A

T22.392D

T22.392S

T22.399A

T22.399D

T22.399S

T23.302A

T23.302D

T23.302S

T23.309A

T23.309D

T23.309S

T23.311A

T23.311D

T23.311S

T23.312A

T23.312D

T23.312S

T23.319A

T23.319D

T23.319S

T23.321A

T23.321D

T23.321S

T23.322A

T23.322D

T23.322S

T23.329A

T23.329D

T23.329S

T23.331A

T23.331D

T23.331S

T23.332A

T23.332D

T23.332S

T23.339A

T23.339D

T23.339S

T23.341A

T23.341D

T23.341S

T23.342A

T23.342D

T23.342S

T23.349A

T23.349D

T23.349S

T23.351A

T23.351D

T23.351S

T23.352A

T23.352D

T23.352S

T23.359A

T23.359D

T23.359S

T23.361A

T23.361D

T23.361S

T23.362A

T23.362D

T23.362S

T23.369A

T23.369D

T23.369S

T23.371A

T23.371D

T23.371S

T23.372A

T23.372D

T23.372S

T23.379A

T23.379D

T23.379S

T23.391A

T23.391D

T23.391S

T23.392A

T23.392D

T23.392S

T23.399A

T23.399D

T23.399S

T24.302A

T24.302D

T24.302S

T24.309A

T24.309D

T24.309S

T24.311A

T24.311D

T24.311S

T24.312A

T24.312D

T24.312S

T24.319A

T24.319D

T24.319S

T24.321A

T24.321S

T24.322A

T24.322D

T24.322S

T24.329A

T24.329D

T24.329S

T24.331A

T24.331D

T24.331S

T24.332A

T24.332D

T24.332S

T24.339A

T24.339D

T24.339S

T24.391A

T24.391D

T24.391S

T24.392A

T24.392D

T24.392S

T24.399A

T24.399D

T24.399S

T25.311A

T25.311D

T25.311S

T25.312A

T25.312D

T25.312S

T25.319A

T25.319D

T25.319S

T25.321A

T25.321D

T25.321S

T25.322A

T25.322D

T25.322S

T25.329A

T25.329D

T25.329S

T25.331A

T25.331D

T25.331S

T25.332A

T25.332D

T25.332S

T25.339A

T25.339D

T25.339S

T25.391A

T25.391D

T25.391S

T25.392A

T25.392D

T25.392S

T25.399A

T25.399D

T25.399S

Z92.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Adopt policy to mirror pharmacy policy

Internal Medical Policy Committee 11-23-2021 Updated criteria to mirror pharmacy policy updates

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Added criteria for long-acting growth hormone, Skytrofa to the policy,
Removed Diagnosis codes E34.3 and Q85.8 and
Added E34.30, E34.31, E34.328, E34.329, and E34.39.

Internal Medical Policy Committee 3-23-2023 - Effective April 01, 2023

Added Genotropin as a preferred product
Added medical benefit specific criteria
Removed "The requested quantity (dose) is within FDA labeled dosing for the requested indication" criteria
Removed length of approval
Updated experimental/investigational statement

Internal Medical Policy Committee 11-15-2023 Effective December 01, 2023

Added Omnitrope as a preferred product
Updated adult specific initial and reauthorization criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-9012-004

Section: Injections

Effective Date: January 01, 2021

Revised Date: March 06, 2023

Revision Effective Date: April 01, 2023

Last Reviewed: March 23, 2023

Archived Date: November 30, 2023

Applies To: Commercial Only

Description

Human growth hormone is a self-administered medication and is covered under the pharmacy benefit.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Preferred Agent
Genotropin^®, Genotropin^® MiniQuick (somatropin)
Norditropin^® FlexPro^® (somatropin)
Nonpreferred Agents
Humatrope^®, Humatropen^® (somatropin)
Nutropin AQ^® NuSpin^® (somatropin)
Omnitrope^® (somatropin)
Saizen^®, saizenprep^® (somatropin)
Serostim^® (somatropin)
Zomacton^® (somatropin)
Zorbtive^® (somatropin)
Long-Acting Growth Hormone
Skytrofa^® (lonapegsomatropin-tcgd)

Human Growth Hormone should be billed through a member's pharmacy benefit but may be considered medically necessary to bill through a member's medical benefit if the following criteria is met:

ONE of the following:
- The individual is receiving the human growth hormone for training and education purposes; or
- The individual's primary insurance requires medical claim processing; or
- A medical reason is provided as to why an individual cannot self-administer (i.e., physical disability, anxiety/panic attack, previous severe reaction to the human growth hormone; or
- The individual is hospitalized; and
The individual must also meet the below specific criteria for the requested product for a child or adult (as defined by the prescriber).

Procedure Codes

J2941

J3590

SHORT-ACTING GROWTH HORMONE

Children - Initial Criteria

Short-acting human growth hormone may be considered medically necessary in the treatment of children when ALL of the following are met:

The individual is a child (as defined by the prescriber); and
The individual has ONE of the following diagnoses:
- The individual is a newborn (less than or equal to four (4) months of age) with hypoglycemia AND serum growth hormone (GH) concentration less than or equal to 5 mcg/L AND at least ONE of the following:
  - Congenital pituitary abnormality (e.g., ectopic posterior pituitary and pituitary hypoplasia with abnormal stalk); or
  - Deficiency of at least one additional pituitary hormone; or
- The individual is a newborn (less than or equal to four (4) months of age) with hypoglycemia AND growth hormone (GH) concentration less than 20 mcg/L AND BOTH of the following:
  - The individual does not have a known metabolic disorder; and
  - The individual has a reduced IGFBP-3 level (e.g., less than -2 SD); or
- The individual has a diagnosis of Turner syndrome; or
- The individual has a diagnosis of Noonan syndrome; or
- The individual has a diagnosis of Prader-Willi syndrome; or
- The individual has a diagnosis of SHOX gene deficiency; or
- The individual has a diagnosis of short bowel syndrome (SBS) AND is receiving specialized nutritional support AND ONE of the following:
  - The individual's age is within FDA labeling for the requested indication for the requested agent; or
  - The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; or
- The individual has a diagnosis of panhypopituitarism or has deficiencies in at least three (3) or more pituitary axes AND serum IGF-I levels below the age- and sex-appropriate reference range when off GH therapy; or
- The individual has a diagnosis of chronic renal insufficiency and BOTH of the following:
  - The individual's height velocity (HV) for age is less than -1.88 standard deviations (SD) OR HV for age is less than the third percentile; and
  - Other etiologies for growth impairment have been addressed; or
- The individual has a diagnosis of small for gestational age (SGA) and ALL of the following:
  - The individual is two (2) years of age or older; and
  - The individual has a documented birth weight and/or birth length that is two (2) or more standard deviations (SD) below the mean for gestational age; and
  - At 24 months of age, the individual failed to manifest catch-up growth evidenced by a height that remains two (2) or more standard deviations (SD) below the mean for age and sex; or
- The individual has a diagnosis of idiopathic short stature (ISS) AND ALL of the following:
  - The individual has a height less than or equal to -2.25 SD below the corresponding mean height for age and sex; and
  - The individual has open epiphyses; and
  - ONE of the following:
    - The individual has a predicted adult height that is below the normal range AND ONE of the following:
      - The individual's sex is male and predicted adult height is less than 63 inches; or
      - The individual's sex is female and predicted adult height is less than 59 inches; or
    - The individual is more than two (2) SD below their mid-parental target height; and
  - BOTH of the following:
    - The individual has been evaluated for constitutional delay of growth and puberty (CDGP); and
    - The individual does NOT have a diagnosis of CDGP; or
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  - The individual has extreme short stature (e.g., height less than or equal to -3 SD), normal nutrition, significantly reduced IGF-1 and IGFBP-3 (e.g., less than -2 SD), and delayed bone age; or
  - BOTH of the following:
    - The individual has ONE of the following:
      - Height more than two (2) SD below the mean for age and sex; or
      - Height more than 1.5 SD below the midparental height; or
      - A decrease in height SD of more than 0.5 over one year in children greater than two (2) years of age; or
      - Height velocity (HV) more than two (2) SD below the mean over one year or more than 1.5 SD sustained over two (2) years; or
      - Height-for-age curve that has deviated downward across two major height percentile curves (e.g., from above the 25 ^th percentile to below the 10 ^th percentile); or
      - BOTH of the following:
        
        The individual's age is 2-4 years; and
        The individual has a HV less than 5.5 cm/year (less than 2.2 inches/year); or
      - BOTH of the following:
        
        The individual's age is 4-6 years; and
        The individual has a HV less than 5 cm/year (less than 2 inches/year); or
      - The individual's age is six (6) years to puberty AND ONE of the following:
        
        The individual's sex is male and HV is less than 4 cm/year (less than 1.6 inches/year); or
        The individual's sex is female and HV is less than 4.5 cm/year (less than 1.8 inches/year); and
    - ONE of the following:
      - The individual has failed at least two (2) GH stimulation tests (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab); or
      - The individual has failed at least one (1) GH stimulation test (e.g., peak GH value of < 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab) AND ONE of the following:
        
        Pathology of the central nervous system; or
        History of irradiation; or
        Other pituitary hormone defects (e.g., multiple pituitary hormone deficiency [MPHD]); or
        A genetic defect; or
      - The individual has a pituitary abnormality and a known deficit of at least one other pituitary hormone; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
ONE of the following:
- The request is for a preferred agent; or
- The request is for a nonpreferred agent and ONE of the following:
  - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over the preferred agent for the intended diagnosis (medical record required).

Procedure Codes

J2941

Children - Reauthorization Criteria

Short-acting human growth hormone may be considered medically necessary in the treatment of children when ALL of the following are met:

The individual has been previously approved for therapy with GH through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- The request is for a preferred agent; or
- The request is for a nonpreferred agent and ONE of the following:
  - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over the preferred agent for the intended diagnosis (medical record required); and
ONE of the following:
- The individual has a diagnosis of short bowel syndrome (SBS) AND has had clinical benefit with the requested agent AND ONE of the following:
  - The individual's age is within FDA labeling for the requested indication for the requested agent; or
  - The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; or
- The individual has a diagnosis of ISS and BOTH of the following:
  - Growth velocity is greater than two (2) cm/year; and
  - Bone age is less than 16 years in individuals with a sex of male and 15 years in individuals with a sex of female AND the individual has open epiphyses; or
- The individual has any other diagnosis AND ALL of the following:
  - The individual does not have closed epiphyses; and
  - The individual's height has increased or height velocity has improved since initiation or last GH approval; and
The individual is being monitored for adverse effects of GH; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis.

Procedure Codes

J2941

Adults - Initial Criteria

Short acting human growth hormone may be considered medically necessary in the treatment of adults when ALL of the following are met

The individual is an adult (as defined by the prescriber); and
The individual has ONE of the following diagnoses:
- The individual has a diagnosis of AIDS wasting/cachexia AND ALL of the following:
  - The individual is currently treated with antiretroviral therapy; and
  - The individual will continue antiretroviral therapy in combination with the requested agent; and
  - BOTH of the following:
    - ONE of the following:
      - The individual has had weight loss that meets ONE of the following:
        
        10% unintentional weight loss over 12 months; or
        7.5% unintentional weight loss over six (6) months; or
      - The individual has a body cell mass (BCM) loss greater than or equal to five (5)% within six (6) months; or
      - The individual's sex is male and has BCM less than 35% of total body weight and body mass index (BMI) less than 27 kg/m ² ; or
      - The individual's sex is female and has BCM less 23% of total body weight and BMI less 27 kg/m ² ; or
      - The prescriber has provided information that the individual's BCM less than 35% or less than 23% and BMI less than 27 kg/m ² are medically appropriate for diagnosing AIDS wasting/cachexia for the individual's sex; or
      - The individual's BMI is less than 20 kg/m ² ; and
    - All other causes of weight loss have been ruled out; or
- The individual has a diagnosis of short bowel syndrome (SBS) AND is receiving specialized nutritional support AND ONE of the following:
  - The individual's age is within FDA labeling for the requested indication for the requested agent; or
  - The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; or
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  - The individual had a diagnosis of childhood-onset growth hormone deficiency AND has failed at least one (1) growth hormone (GH) stimulation test as an adult; or
  - The individual has a low insulin-like growth factor-1 (IGF-1) level AND ONE of the following:
    - Organic hypothalamic-pituitary disease; or
    - Pituitary structural lesion or trauma; or
    - The individual has panhypopituitarism or multiple (greater than or equal to three (3)) pituitary hormone deficiency; or
  - The individual has an established causal genetic mutation OR hypothalamic-pituitary structural defect other than ectopic posterior pituitary; or
  - The individual has failed at least two (2) growth hormone (GH) stimulation tests as an adult; or
  - The individual has failed at least one (1) GH stimulation test as an adult AND the individual has an organic pituitary disease; and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis; and
ONE of the following:
- The request is for a preferred agent; or
- If the request is for a nonpreferred agent, ONE of the following:
  - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over the preferred agent for the intended diagnosis (medical record required).

Procedure Codes

J2941

Adults - Reauthorization Criteria

Short-acting human growth hormone may be considered medically necessary in adults when ALL of the following are met:

The individual has been approved for therapy with GH previously through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is an adult (as defined by the prescriber); and
ONE of the following:
- The request is for a preferred agent; or
- The request is for a nonpreferred agent AND ONE of the following:
  - The individual has an intolerance, FDA labeled contraindication, or hypersensitivity to a preferred agent that is not expected to occur with the requested nonpreferred agent (medical record required); or
  - The prescriber has provided information to support the efficacy of the requested nonpreferred agent over the preferred agent for the intended diagnosis (medical record required)
ONE of the following:
- The individual has a diagnosis of short bowel syndrome (SBS) AND has had clinical benefit with the requested agent; or
- The individual has a diagnosis of AIDS wasting/cachexia AND ALL of the following:
  - The individual is currently treated with antiretroviral therapy; and
  - The individual will continue antiretroviral therapy in combination with the requested agent; and
  - The individual has had clinical benefit with the requested agent (i.e., an increase in weight or weight stabilization); or
- The individual has any other diagnosis AND BOTH of the following:
  - The individual's IGF-I level has been evaluated to confirm the appropriateness of the current dose; and
  - The individual has had clinical benefit with the requested agent (i.e., body composition, hip-to-waist ratio, cardiovascular health, bone mineral density, serum cholesterol, physical strength, or quality of life); and
The individual does NOT have any FDA labeled contraindications to the requested agent; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual is being monitored for adverse effects of GH.

Procedure Codes

J2941

LONG-ACTING GROWTH HORMONE

Children - Initial Criteria

Long-acting human growth hormone may be considered medically necessary in adults when ALL of the following are met:

ONE of the following:
- The individual has an FDA approved indication for the requested agent; or
- The individual has another indication that is supported in compendia for the requested agent and route of administration; and
ONE of the following:
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND ONE of the following:
  - The individual has extreme short stature (e.g., height less than or equal to -3 SD), normal nutrition, significantly reduced IGF-1 and IGFBP-3 (e.g., less than -2 SD), and delayed bone age; or
  - BOTH of the following:
    - The individual has ONE of the following:
      - Height more than two (2) SD below the mean for age and sex; or
      - Height more than 1.5 SD below the midparental height; or
      - A decrease in height SD of more than 0.5 over one year in children greater than two (2) years of age; or
      - Height velocity (HV) more than two (2) SD below the mean over one year or more than 1.5 SD sustained over two years; or
      - Height-for-age curve that has deviated downward across two major height percentile curves (e.g., from above the 25 ^th percentile to below the 10 ^th percentile); or
      - BOTH of the following:
        
        The individual's age is 2-4 years; and
        The individual has a HV less than 5.5 cm/year (less than 2.2 inches/year); or
      - BOTH of the following:
        
        The individual's age is 4-6 years; and
        The individual has a HV less than 5 cm/year (less than 2 inches/year); or
      - The individual's age is six (6) years to puberty AND ONE of the following:
        
        The individual's sex is male and HV is less than 4 cm/year (less than 1.6 inches/year); or
        The individual's sex is female and HV is less than 4.5 cm/year (less than 1.8 inches/year); and
    - ONE of the following:
      - The individual has failed at least two (2) GH stimulation tests (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab); or
      - The individual has failed at least one (1) GH stimulation test (e.g., peak GH value of less than 10 mcg/L after stimulation, or otherwise considered abnormal as determined by testing lab) AND ONE of the following:
        
        Pathology of the central nervous system; or
        History of irradiation; or
        Other pituitary hormone defects (e.g., multiple pituitary hormone deficiency [MPHD]); or
        A genetic defect; or
      - The individual has a pituitary abnormality and a known deficit of at least one other pituitary hormone; or
- The individual has another FDA approved or compendia supported indication for the requested agent and route of administration; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- The individual's age is within FDA labeling for the requested indication for the requested agent; or
- The prescriber has provided information in support of using the requested agent for the individual's age for the requested indication; and
ONE of the following:
- BOTH of the following:
  - The individual has received a trial of the preferred short-acting GH for at least 12 months (medical record required); and
  - The individual has failed to achieve a two (2) cm/year growth velocity due to lack of adherence to a preferred short-acting GH (medical record required); or
- The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent (medical record required); and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual does NOT have any FDA labeled contraindications to the requested agent.

Procedure Codes

J3590

Children - Reauthorization Criteria

Short-acting human growth hormone may be considered medically necessary in the treatment of children when ALL of the following are met:

Children - Renewal Evaluation

Long-Acting Growth Hormone Agent(s) will be approved when ALL of the following are met:

The individual has been approved for therapy with GH previously through Blue Cross Blue Shield of North Dakota's prior authorization process; and
The individual is a child (as defined by the prescriber); and
ONE of the following:
- BOTH of the following:
  - The individual has received a trial of the preferred short-acting GH for at least 12 months (medical record required); and
  - The individual has failed to achieve a two (2) cm/year growth velocity due to lack of adherence to a preferred short-acting GH (medical record required); or
- The individual has an intolerance, hypersensitivity or FDA labeled contraindication to a preferred short-acting growth hormone that is not expected to occur with the requested nonpreferred agent (medical record required); and
ONE of the following:
- The individual has a diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone AND BOTH of the following:
  - The individual does NOT have closed epiphyses; and
  - The individual's height has increased or height velocity has improved since initiation or last GH approval; or
- BOTH of the following:
  - The individual has another FDA approved or compendia supported indication for the requested agent and route of administration; and
  - The individual has had clinical benefit with the requested agent; and
The individual is being monitored for adverse effects of GH; and
The prescriber is a specialist in the area of the individual's diagnosis (e.g., endocrinologist) or has consulted with a specialist in the area of the individual's diagnosis; and
The individual does NOT have any FDA labeled contraindications to the requested agent.

Procedure Codes

J3590

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

NOTE: Compendia Allowed: DrugDex 1 or 2a level of evidence

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code J2941

B20

C75.1

C75.2

C79.9

D33.0

D33.1

D33.2

D35.2

D35.3

D44.3

D44.4

D49.7

E23.0

E23.1

E23.3

E23.6

E23.7

E34.30

E34.31

E34.328

E34.329

E34.39

E89.3

N18.30

N18.31

N18.32

N18.4

N18.5

N18.6

N18.9

N25.0

P05.10

P05.11

P05.12

P05.13

P05.14

P05.15

P05.16

P05.17

P05.18

P05.19

Q85.00

Q85.01

Q85.02

Q85.03

Q85.09

Q85.9

Q87.11

Q87.19

Q87.5

Q96.0

Q96.1

Q96.2

Q96.3

Q96.4

Q96.8

Q96.9

R62.0

R62.50

R62.51

R64

T20.30XA

T20.30XD

T20.30XS

T20.311A

T20.311D

T20.311S

T20.312A

T20.312D

T20.312S

T20.319A

T20.319D

T20.319S

T20.33XA

T20.33XD

T20.33XS

T20.34XA

T20.34XD

T20.34XS

T20.35XA

T20.35XD

T20.35XS

T20.36XA

T20.36XD

T20.36XS

T20.37XA

T20.37XD

T20.37XS

T20.39XA

T20.39XD

T20.39XS

T22.30XA

T22.30XD

T22.30XS

T22.311A

T22.311D

T22.311S

T22.312A

T22.312D

T22.312S

T22.319A

T22.319D

T22.319S

T22.321A

T22.321D

T22.321S

T22.322A

T22.322D

T22.322S

T22.329A

T22.329D

T22.329S

T22.331A

T22.331D

T22.331S

T22.332A

T22.332D

T22.332S

T22.339A

T22.339D

T22.339S

T22.341A

T22.341D

T22.341S

T22.342A

T22.342D

T22.342S

T22.349A

T22.349D

T22.349S

T22.351A

T22.351D

T22.351S

T22.352A

T22.352D

T22.352S

T22.359A

T22.359D

T22.359S

T22.361A

T22.361D

T22.361S

T22.362A

T22.362D

T22.362S

T22.369A

T22.369D

T22.369S

T22.391A

T22.391D

T22.391S

T22.392A

T22.392D

T22.392S

T22.399A

T22.399D

T22.399S

T23.302A

T23.302D

T23.302S

T23.309A

T23.309D

T23.309S

T23.311A

T23.311D

T23.311S

T23.312A

T23.312D

T23.312S

T23.319A

T23.319D

T23.319S

T23.321A

T23.321D

T23.321S

T23.322A

T23.322D

T23.322S

T23.329A

T23.329D

T23.329S

T23.331A

T23.331D

T23.331S

T23.332A

T23.332D

T23.332S

T23.339A

T23.339D

T23.339S

T23.341A

T23.341D

T23.341S

T23.342A

T23.342D

T23.342S

T23.349A

T23.349D

T23.349S

T23.351A

T23.351D

T23.351S

T23.352A

T23.352D

T23.352S

T23.359A

T23.359D

T23.359S

T23.361A

T23.361D

T23.361S

T23.362A

T23.362D

T23.362S

T23.369A

T23.369D

T23.369S

T23.371A

T23.371D

T23.371S

T23.372A

T23.372D

T23.372S

T23.379A

T23.379D

T23.379S

T23.391A

T23.391D

T23.391S

T23.392A

T23.392D

T23.392S

T23.399A

T23.399D

T23.399S

T24.302A

T24.302D

T24.302S

T24.309A

T24.309D

T24.309S

T24.311A

T24.311D

T24.311S

T24.312A

T24.312D

T24.312S

T24.319A

T24.319D

T24.319S

T24.321A

T24.321S

T24.322A

T24.322D

T24.322S

T24.329A

T24.329D

T24.329S

T24.331A

T24.331D

T24.331S

T24.332A

T24.332D

T24.332S

T24.339A

T24.339D

T24.339S

T24.391A

T24.391D

T24.391S

T24.392A

T24.392D

T24.392S

T24.399A

T24.399D

T24.399S

T25.311A

T25.311D

T25.311S

T25.312A

T25.312D

T25.312S

T25.319A

T25.319D

T25.319S

T25.321A

T25.321D

T25.321S

T25.322A

T25.322D

T25.322S

T25.329A

T25.329D

T25.329S

T25.331A

T25.331D

T25.331S

T25.332A

T25.332D

T25.332S

T25.339A

T25.339D

T25.339S

T25.391A

T25.391D

T25.391S

T25.392A

T25.392D

T25.392S

T25.399A

T25.399D

T25.399S

Z92.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Adopt policy to mirror pharmacy policy

Internal Medical Policy Committee 11-23-2021 Updated criteria to mirror pharmacy policy updates

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Added criteria for long-acting growth hormone, Skytrofa to the policy,
Removed Diagnosis codes E34.3 and Q85.8 and
Added E34.30, E34.31, E34.328, E34.329, and E34.39.

Internal Medical Policy Committee 3-23-2023 - Effective April 01, 2023

Added Genotropin as a preferred product
Added medical benefit specific criteria
Removed "The requested quantity (dose) is within FDA labeled dosing for the requested indication" criteria
Removed length of approval
Updated experimental/investigational statement

Medical Policies Quick Search