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Prior Authorization

Growth Hormone

Documentation Needed for Adult Growth Hormone Initial Review

THIS IS A CONTRACT ISSUE. IF IT DOES NOT MEET THE CRITERIA BELOW, IT IS A CONTRACT EXCLUSION AND NOT ELIGIBLE FOR REVIEW BY AN OUTSIDE CONSULANT.

Thorough history & physical prior to beginning treatment-giving rationale for recommending growth hormone. This should include:

1. Results of insulin tolerance test or if for some reason this is contraindicated – a test with GHRH together with arginine can be substituted and/or
2. Any history of head trauma, radiation or brain tumor
3. Any other endocrine problems

Continuation

For continuation of growth hormone there should be a summary of the proceeding 12-months by physician documenting:

Weight loss (3 measurements)
Improved lipid profile
Increased bone mass
Increased muscle strength
Increased IGF1 to normal range
Increased lean body mass
Decreased in fat mass
Increased bone mass (DEXA Scan)

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