CSHCN Services Program 2010 > Physician > Benefits, Limitations, and Authorization Requirements

   
 

30.2.24.7 Growth Hormone

The Vendor Drug Program (VDP) reimburses growth hormone (hGH) injections for CSHCN Services Program clients for any of the following diagnosis codes:

Diagnosis Codes

1933

2370

2532

2533

2537

5851

5852

5853

5854

5855

5856

5859

58889

7586

75981

Pharmacies must submit claims to the VDP. Pharmacies are reimbursed the same drug costs and dispensing fees allowed by the Texas Medicaid VDP.

Providers may refer to the Texas Health and Human Services Commission Texas Medicaid/CHIP Vendor Drug Program website at www.hhsc.state.tx.us/HCF/vdp/vdpstart.html for more information about the VDP, including available drugs.

Prior Authorization Requirements

Requests for prior approval of the medical criteria for growth hormone therapy must be submitted to the Texas Medicaid VDP by a program-approved endocrinologist using the "Growth Hormone Approval Request Form." The following criteria must be met:

Normal thyroid function or may be corrected with medication

Normal pituitary function studies or may be corrected with medication

Documentation of open epiphyses (done in last 12 months)

Evidence of deficient growth hormone (GH) production on two pharmacological provocative tests (GH peak less than 10 ng/ml)

Physical stature less than the 3rd percentile

Growth velocity 4cm or less per year

Below normal somatomedin C level or insulin-like growth factor binding protein 3 (IGF/BP3)

Nutropin® is the only product approved for the treatment of chronic renal failure, and Genotropin® is the only product approved for the treatment of Prader-Willi syndrome.

Note: Clients with Turner's syndrome or Prader-Willi syndrome may be approved without evidence of deficient growth hormone production on provocative testing if other criteria are met.

Initial approval is for a 6-month period. Requests for extensions may be granted for an additional 12 months at a time. Approval for continued growth hormone therapy may be granted if the following criteria are met:

Growth chart documents growth equal to a minimum of 4cm per year and documents a significant increase from pretreatment levels

Epiphyses must be open

Bone age must be documented annually after a boy has reached a chronological age of 16 years and a girl has reached a chronological age of 14 years.

If an initial or extension request cannot be approved based on the above criteria, the approval request may be sent for medical review and reconsideration to the CSHCN Services Program.

Refer to: Section 3.1.2, "Prescription Benefits Processed by the Texas Medicaid/CHIP Vendor Drug Program (VDP)" for more information about the VDP.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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