![]() Pretreatment 1-year height velocity is greater than 2 SD below the mean and.Pretreatment height is greater than 2 SD below the mean and 1-year height velocity is greater than 1 SD below the mean or.For members greater than or equal to 2.5 years of age at initiation of treatment:.For members less than 2.5 years of age at initiation of treatment, the pretreatment height is greater than 2 SD below the mean and growth velocity is slow and.A documented pituitary or CNS disorder (see Appendix A) and a pretreatment IGF-1 level greater than 2 standard deviations (SD) below the mean and.Two pretreatment pharmacologic provocative GH tests with both results demonstrating a peak GH level less than 10 ng/mL, or.Medical records must be available to support the diagnosis of neonatal GH deficiency (e.g., hypoglycemia with random GH level, evidence of multiple pituitary hormone deficiency, chart notes, or magnetic resonance imaging results) or ![]() Member is a neonate or was diagnosed with GH deficiency as a neonate.When either criteria 1 or 2 below is met: Pediatric Growth Hormone (GH) Deficiency.Somatropin Products - Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, and ZomactonĪetna considers somatropin products: Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, and Zomacton medically necessary for the following indications: Medicare Part B plans: Precertification of Serostim, Skytrofa, orSogroya is required for participating providers and members in applicable Medicare Part B plan designs. For precertification of these medications, call (866) 752-7021, or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification. Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background ReferencesĬommercial plans: Precertification of Serostim or Somavert is required of all Aetna participating providers and members in applicable plan designs. ![]()
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