I thought I'd throw this info out there from BCBS's insurance. It gives you an idea of what situations are covered and what isn't. I just included the prerequisites for an adult since most of us are.
**Warning! Long post. Not for the tl;dr.**
When Growth Hormone is covered:
1. Adult onset symptomatic GH deficiency associated with low GH levels (documented by failure of at least two GH stimulation tests). 24-hour continuous measurements of GH, serum levels of IGF-1, or serum levels of IGFBP-3 are considered inadequate to document GH deficiency.
2. Childhood onset symptomatic GH deficiency, where persistent GH deficiency is documented by at least one failed GH stimulation test performed at least 3 months after the cessation of prior GH therapy.
3. Adult onset symptomatic GH deficiency associated with multiple hormone deficiencies (i.e., panhypopituitarism), as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy, or trauma.
The diagnosis of panhypopituitarism is established when either one of the two following criteria (a or b) are met:
a. At least 2 additional hormone deficiencies (other than GH) requiring hormone replacement therapy are documented (e.g., TSH, ACTH, ADH or gonadotropin hormones) as well as failure of at least 1 GH stimulation test, OR
b. Three pituitary hormone deficiencies (other than GH) requiring hormone replacement therapy (where clinically appropriate) are documented AND a low IGF level (below 80 ng/ml) is documented in lieu of GH stimulation testing.
4. Renewal of coverage for adult GH therapy may be granted on an annual basis without additional testing if the original documentation of failed GH stimulation testing is made available with the request for renewal of coverage, and there is continued clinical benefit in symptoms or signs.
Other conditions in which GH therapy may be considered medically necessary and are eligible for coverage include the following:
1. HIV cachexia or "wasting syndrome," defined by unintentional weight loss of at least 10 percent of baseline weight, or BMI < 20 kg/m2, not attributable to other causes (such as AIDS-associated diarrhea, infection, malignancy or depression), when optimal anti-viral therapy has been instituted. Therapy is continued until this definition is no longer met.
2. Short Bowel Syndrome (SBS), defined as the inability to maintain adequate nutritional status without parenteral (intravenous) supplementation required at least 5 days/week for a total of at least 3,000 calories/ week, due to surgical or functional loss of small bowel.
a. Continued coverage for Short Bowel Syndrome will be approved on a quarterly basis (every 3 months) when continued benefit is documented by a sustained decrease in IV nutritional requirements and sustained weight.
3. Promotion of wound healing in children or adults with 3rd degree burns.
When Growth Hormone is not covered:
A. When none of the conditions under "When Covered" are present, OR when any of the conditions for continued therapy ("renewal criteria") are not met, the use of GH therapy will be considered not medically necessary.
B. The use of Growth Hormone for short stature in patients with no proven Growth Hormone deficiency (e.g., idiopathic short stature without evidence of biologic impairment of the growth hormone pituitary axis) is not covered. It is considered cosmetic.
C. Investigational conditions. The use of GH therapy is considered investigational and is not covered for certain conditions, including but not limited to:
1. Constitutional delay (defined as lower than expected height percentiles compared with their target height percentiles and delayed skeletal maturation when growth velocities and rates of bone age advancement are normal.)
2. Therapy for geriatric patients, defined as age >65.
3. Anabolic therapy provided to counteract acute or chronic catabolic illness due to surgery outcomes, trauma (except for children with severe burns or for promotion of wound healing in children or adults with third degree burns), cancer, chronic hemodialysis (except as specified above for chronic renal
insufficiency) or chronic infectious disease producing catabolic (protein wasting) changes in both adult and pediatric patients (except for the specific covered indication of AIDS wasting noted above.)
4. Anabolic therapy provided to enhance body mass or strength for professional, recreational or social reasons.
5. Glucocorticoid-induced growth failure.
6. Short stature after renal transplantation.
7. Short stature due to Bloom or Down Syndrome.
8. Treatment of altered body habitus (e.g., buffalo hump) associated with antiviral therapy in HIV infected patients.
9. Precocious puberty.
10. Obesity.
11. Cystic fibrosis.
12. Idiopathic dilated cardiomyopathy.
13. Infertility.
14. Juvenile rheumatoid (or idiopathic chronic) arthritis.
15. Chronic hepatitis.
16. Diabetes.
