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Human Growth Hormone

Recombinant human growth hormone (GH) therapy may be considered medically necessary for the following patients (see specific patient selection criteria in the Policy Guidelines section):Children with proven growth hormone deficiency

Children with growth failure due to Prader-Willi syndrome, who do not have the following contraindications: severe obesity or a history of upper airway obstruction, sleep apnea, or severe respiratory impairment

Children with a height below the third percentile for chronologic age with chronic renal insufficiency

Patients with Turner syndrome

Patients with short stature due to Noonan syndrome

Children with short stature due to SHOX (short stature homeobox-containing gene) deficiency

Promotion of wound healing in burn patients

Prevention of growth delay in children with severe burns

Patients with AIDS wasting

Patients with short bowel syndrome receiving specialized nutritional support in conjunction with optimal management of short bowel syndrome

Adults with proven growth hormone deficiency.

The following indications approved by the U.S. Food and Drug Administration are considered not medically necessary:

Pediatric patients born small for gestational age who fail to show catch-up growth by age 2 years

Children with height standard deviation score of -2.25 or below without documented growth hormone deficiency.

Recombinant human growth hormone is considered investigational for all other applications including, but not limited to the following:

Treatment of altered body habitus (eg, buffalo hump) associated with antiviral therapy in HIV-infected patients

Constitutional delay (lower than expected height percentiles compared with target height percentiles and delayed skeletal maturation when growth velocities and rates of bone age advancement are normal)

Treatment of children with “genetic potential” (ie, lower than expected height percentiles based on parents’ height)

In conjunction with gonadotropin-releasing hormone analogs as a treatment of precocious puberty

Growth hormone therapy in older adults without proven deficiency

Treatment of cystic fibrosis

Anabolic therapy (except for AIDS) provided to counteract acute or chronic catabolic illness (eg, surgery outcomes, trauma, cancer, chronic hemodialysis, chronic infectious disease) producing catabolic (protein wasting) changes in both adult and pediatric patients

Anabolic therapy to enhance body mass or strength for professional, recreational, or social reasons

Glucocorticoid-induced growth failure

Short stature due to Down syndrome

Treatment of obesity

Treatment of idiopathic dilated cardiomyopathy

Treatment of juvenile idiopathic or juvenile chronic arthritis.

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