Recombinant human growth hormone (GH) therapy may be considered medically necessary for the following individuals (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
Individuals with Turner syndrome
Individuals 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 individuals with burns
Prevention of growth delay in children with severe burns
Individuals with AIDS wasting
Individuals with short bowel syndrome receiving specialized nutritional support in conjunction with optimal management of short bowel syndrome
Adults with proven growth hormone deficiency.
Recombinant human growth hormone is considered investigational for all other applications including, but not limited to the following:
Children 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.
Treatment of altered body habitus (eg, buffalo hump) associated with antiviral therapy in HIV-infected individuals
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 individuals
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.