Growth Hormone (Gh) Therapy - Medical Necessity Request Form (Page 2 of 3) in pdf

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

Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________

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

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

□ Prader-Willi syndrome

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

- Is the member severely obese? Yes or No

- Does the member have severe respiratory impairment? Yes or No

□ Noonan Syndrome

□ SHOX (short stature homeobox-containing) deficiency

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

□ Small for gestational age (including Russel Silver variant of intrauterine growth retardation)

- Birth Weight: ____________

- Gestational Age: _________

- Was birth weight or length 2 standard deviations (SD) or more below mean for gestational age and gender? Yes or No

- Was the birth weight or length below the 3

percentile for gestational age? Yes or No

- Has the member failed to catch-up on height by age 2? Yes or No

**Please submit documentation of growth charts plotted. **

□ Adult GH deficiency – Please specify type of onset and answer associated questions.

□ Adult Onset *Please submit documentation for all of the following questions

- How many deficient hormones does the member have? __________

- Does the member have a history of head injury, cranial irradiation, subarachnoid hemorrhage or hypothalamic disease? Yes or No

□ Childhood Onset

- Was the member diagnosed with growth hormone deficiency as a child? Yes or No

- How many deficient hormones does the member have? _________ *Please submit documentation

- Has the member achieved final height? Yes or No

- If Yes, was therapy stopped for at least 1 month and the member was re-tested? Yes or No

- Does the member have irreversible hypothalamic-pituitary structural lesions (including structural hypothalamic-pituitary disease, or

central nervous system tumors)? Yes or No *Please submit documentation

- Does the member have congenital/embryopathic defects? Yes or No *Please submit documentation

□ HIV/AIDS wasting syndrome

- Does member have a confirmed diagnosis of HIV or AIDS Wasting Syndrome or cachexia? Yes or No

- Is member currently receiving and will continue to receive antiretroviral therapy? Yes or No

- Baseline pre-morbid weight: __________ Date Measured: ________

- Has member tried and failed at least 2 non-invasive forms of nutritional therapy (e.g., nutritional supplements, megestrol acetate, dronabinol)

and is otherwise candidates for assisted enteral/total parenteral nutrition?

□ Yes - Please provide the names of the therapies: _________________________________________________

□ No

- How many weeks supply is being requested? __________________________________________________________

□ Idiopathic short stature

- Is growth rate unlikely to permit attainment of adult height in the normal range? Yes or No

- Does the member have a height at least 2.25 standard deviations below the mean for age and sex? Yes or No

- Is the member prepubertal? Yes or No

- Have other causes of short stature, including growth hormone deficiency, and familial short stature been excluded? Yes or No

□ Short bowel syndrome

- Is member managed by a Gastroenterologist and/or Endocrinologist? Yes or No

- Is the member receiving specialized nutritional support? Yes or No

□ Other (please specify): ____________________________

Physician office's signature*_________________________________ Print Name________________________________

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

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Rev. 03/16

HNJH Fax #: 888-567-0681

Page

Growth Hormone (Gh) Therapy - Medical Necessity Request Form Page 2

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