Growth Hormone (Gh) Therapy - Medical Necessity Request Form printable pdf download

Member Name: ______________________________ Member ID: ________________ Member DOB: ________________

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________

Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________

Horizon NJ Health

Growth Hormone (GH) Therapy – Medical Necessity Request

**Please complete pages 1 and 2 for New/Initial requests**

General Information

Current Ht*: ___________inches or _________cm Date: _________

Contraindication Information

Current Wt: ________ lbs or _______kg

Date: _________

* For Pediatric Patients, please provide most recent growth chart.

Does member have any of the following:



Active neoplasia or tumor activity? Yes

Height Standard Deviation: __________

or No

GH Stimulation Test(s):



ITT: __________ Date: _________

Active Proliferative or severe non-

GHRH + ARG: __________ Date: _________

proliferative diabetic retinopathy?

Yes

Glucagon: __________ Date: _________

or No

ARG: __________ Date: _________



Closed epiphyses or epiphyseal fusion? Yes

IGF-1: Below normal? Yes or No Percentile for age/sex: _______

or No

IGFBP3: Below normal? Yes or No Percentile for age/sex: _______

Please provide documentation for all lab/test values

Is the member being managed by an Endocrinologist? Yes or No

Diagnosis Information (please select diagnosis and provide requested information below the diagnosis):

□

Pediatric GH deficiency, Isolated GH Deficiency, Pituitary Dwarfism, Hypopituitarism or Panhypopituitarism

Does the member have an anatomical absence of the pituitary? Yes or No

Does the member have signs of multiple pituitary hormone deficiencies (MPHD)? Yes or No

Does the member have evidence of another pituitary hormone deficiency? Yes or No

Has the member has received treatment known to cause growth hormone deficiency (e.g., cranial irradiation)? Yes or No

*If all of the above were answered No, please answer the following questions:

Is the member's height more than 2 standard deviations (SD) below the population mean? Yes or No

Is the member’s height > 1.5 SD below midparental height (average of mother’s and father’s heights)? Yes or No

Does the member have a 1 year height velocity of > 2 SD below the mean? Yes or No

Does the member have a 2-year height velocity of > 1.5 SD below the mean? Yes or No

Has the member failed 2 growth hormone stimulation tests (i.e., ITT, GHRH+ARG, glucagon, ARG tests, clonidine, levodopa)

with growth hormone levels less than 10 ng/mL? Yes or No

Has the member failed at least 1 growth hormone stimulation test with a growth hormone level less than 10 ng/mL (e.g., ITT,

GHRH+ARG, glucagon or ARG tests, clonidine, levodopa) AND IGF-I and IGFBP3 levels are below normal for bone age and

gender? Yes or No

□ Turner syndrome

- Has diagnosis been confirmed by appropriate genetic testing? Yes or No *Please submit documentation

- Is the member’s height percentile is below the 5

percentile for age and sex? Yes or No

- What is the member’s height taken within the past 60 days? ____________inches OR __________cm

□ Chronic renal insufficiency * Please submit documentation for all of the following questions

- What is the member’s Glomerular Filtration Rate (GFR)? __________________

- Is the member on dialysis? Yes or No

- Does the member have normal metabolic and nutritional status?

□ Yes

□ No – Are all growth-inhibiting metabolic derangements (e.g., acidosis, secondary hyperparathyroidism, undernutrition) being

managed? Yes or No

- Has member undergone renal transplantation?

□ Yes - Is the transplant failing? Yes or No

□ No

Physician office's signature*_________________________________ Print Name________________________________

*Form must be completed and signed by physician or licensed representative from the physician’s office.

1 of 3

Rev. 03/16

HNJH Fax #: 888-567-0681

Page

Growth Hormone (Gh) Therapy - Medical Necessity Request Form

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